Catheter apparatuses having multi-electrode arrays for renal neuromodulation and associated systems and methods

ABSTRACT

Catheter apparatuses, systems, and methods for achieving renal neuromodulation by intravascular access are disclosed herein. One aspect of the present technology, for example, is directed to a treatment device having a multi-electrode array configured to be delivered to a renal blood vessel. The array is selectively transformable between a delivery or low-profile state (e.g., a generally straight shape) and a deployed state (e.g., a radially expanded, generally helical shape). The multi-electrode array is sized and shaped so that the electrodes or energy delivery elements contact an interior wall of the renal blood vessel when the array is in the deployed (e.g., helical) state. The electrodes or energy delivery elements are configured for direct and/or indirect application of thermal and/or electrical energy to heat or otherwise electrically modulate neural fibers that contribute to renal function or of vascular structures that feed or perfuse the neural fibers.

CROSS-REFERENCE TO RELATED APPLICATION(S)

This application claims the benefit of the following pendingapplications:

(a) U.S. Provisional Application No. 61/406,531, filed Oct. 25, 2010;

(b) U.S. Provisional Application No. 61/406,960, filed Oct. 26, 2010;

(c) U.S. Provisional Application No. 61/572,290, filed Jan. 28, 2011;

(d) U.S. Provisional Application No. 61/528,001, filed Aug. 25, 2011;

(e) U.S. Provisional Application No. 61/528,086, filed Aug. 26, 2011;

(f) U.S. Provisional Application No. 61/528,091, filed Aug. 26, 2011;

(g) U.S. Provisional Application No. 61/528,108, filed Aug. 26, 2011;

(h) U.S. Provisional Application No. 61/528,684, filed Aug. 29, 2011;and

(i) U.S. Provisional Application No. 61/546,512, filed Oct. 12, 2011.

All of the foregoing applications are incorporated herein by referencein their entireties. Further, components and features of embodimentsdisclosed in the applications incorporated by reference may be combinedwith various components and features disclosed and claimed in thepresent application.

TECHNICAL FIELD

The present technology relates generally to renal neuromodulation andassociated systems and methods. In particular, several embodiments aredirected to multi-electrode radio frequency (RF) ablation catheterapparatuses for intravascular renal neuromodulation and associatedsystems and methods.

BACKGROUND

The sympathetic nervous system (SNS) is a primarily involuntary bodilycontrol system typically associated with stress responses. Fibers of theSNS innervate tissue in almost every organ system of the human body andcan affect characteristics such as pupil diameter, gut motility, andurinary output. Such regulation can have adaptive utility in maintaininghomeostasis or in preparing the body for rapid response to environmentalfactors. Chronic activation of the SNS, however, is a common maladaptiveresponse that can drive the progression of many disease states.Excessive activation of the renal SNS in particular has been identifiedexperimentally and in humans as a likely contributor to the complexpathophysiology of hypertension, states of volume overload (such asheart failure), and progressive renal disease. For example, radiotracerdilution has demonstrated increased renal norepinephrine (NE) spilloverrates in patients with essential hypertension.

Cardio-renal sympathetic nerve hyperactivity can be particularlypronounced in patients with heart failure. For example, an exaggeratedNE overflow from the heart and kidneys to plasma is often found in thesepatients. Heightened SNS activation commonly characterizes both chronicand end stage renal disease. In patients with end stage renal disease,NE plasma levels above the median have been demonstrated to bepredictive for cardiovascular diseases and several causes of death. Thisis also true for patients suffering from diabetic or contrastnephropathy. Evidence suggests that sensory afferent signals originatingfrom diseased kidneys are major contributors to initiating andsustaining elevated central sympathetic outflow.

Sympathetic nerves innervating the kidneys terminate in the bloodvessels, the juxtaglomerular apparatus, and the renal tubules.Stimulation of the renal sympathetic nerves can cause increased reninrelease, increased sodium (Na⁺) reabsorption, and a reduction of renalblood flow. These neural regulation components of renal function areconsiderably stimulated in disease states characterized by heightenedsympathetic tone and likely contribute to increased blood pressure inhypertensive patients. The reduction of renal blood flow and glomerularfiltration rate as a result of renal sympathetic efferent stimulation islikely a cornerstone of the loss of renal function in cardio-renalsyndrome (i.e., renal dysfunction as a progressive complication ofchronic heart failure). Pharmacologic strategies to thwart theconsequences of renal efferent sympathetic stimulation include centrallyacting sympatholytic drugs, beta blockers (intended to reduce reninrelease), angiotensin converting enzyme inhibitors and receptor blockers(intended to block the action of angiotensin II and aldosteroneactivation consequent to renin release), and diuretics (intended tocounter the renal sympathetic mediated sodium and water retention).These pharmacologic strategies, however, have significant limitationsincluding limited efficacy, compliance issues, side effects, and others.Accordingly, there is a strong public-health need for alternativetreatment strategies.

BRIEF DESCRIPTION OF THE DRAWINGS

Many aspects of the present disclosure can be better understood withreference to the following drawings. The components in the drawings arenot necessarily to scale. Instead, emphasis is placed on illustratingclearly the principles of the present disclosure.

FIG. 1 illustrates an intravascular renal neuromodulation systemconfigured in accordance with an embodiment of the present technology.

FIG. 2 illustrates modulating renal nerves with a multi-electrodecatheter apparatus in accordance with an embodiment of the presenttechnology.

FIG. 3A is a view of a distal portion of a catheter shaft and amulti-electrode array in a delivery state (e.g., low-profile orcollapsed configuration) within a renal artery used in conjunction witha guide catheter in accordance with an embodiment of the presenttechnology.

FIG. 3B is a view of the distal portion of the catheter shaft and themulti-electrode array of FIG. 3A in a deployed state (e.g., expandedconfiguration) within a renal artery in accordance with an embodiment ofthe technology.

FIG. 3C is a partially cutaway, isometric view of a treatment device ina deployed state within a renal artery in accordance with an embodimentof the technology.

FIG. 4A is a plan view of a treatment assembly for use in a treatmentdevice in accordance with an embodiment of the technology.

FIG. 4B is an isometric view of the treatment assembly of FIG. 4A.

FIG. 4C is an end view of the helical structure of FIG. 4B showing theangular offset of energy delivery elements in a treatment assembly inaccordance with an embodiment of the technology.

FIG. 4D is a side view of a vessel with lesions prophetically formed bya treatment assembly that circumferentially and longitudinally overlapbut do not overlap along a helical path.

FIG. 5A-5D illustrate various embodiments of energy delivery elements ordevices for use with the treatment assembly of FIGS. 4A and 4B.

FIG. 5E illustrates an embodiment of a treatment assembly in which thesupport structure is electrically conductive and serves as the energydelivery element.

FIG. 6A illustrates an embodiment of a treatment device including anelongated shaft having different mechanical and functional regionsconfigured in accordance with an embodiment of the technology.

FIG. 6B is a plan view of a slot pattern for use in the treatment deviceof FIG. 6A.

FIG. 6C is a perspective view of a distal portion of the treatmentdevice of FIG. 6A in a delivery state (e.g., low-profile or collapsedconfiguration) outside a patient in accordance with an embodiment of thetechnology.

FIG. 6D is a perspective view of the treatment device of FIG. 6C in adeployed state (e.g., expanded configuration) outside a patient.

FIG. 6E is a partially schematic plan view of a distal region of thesupport structure of FIG. 6A in a generally helically-shaped deployedstate.

FIG. 6F is a partially schematic plan view of a distal portion of atreatment device of in a polygon-shaped deployed state in accordancewith another embodiment of the technology.

FIG. 6G is a plan view of a slot pattern for use in the treatment deviceof FIG. 6A in accordance with another embodiment of the technology.

FIG. 6H is a perspective view of a support structure for use in atreatment device configured in accordance with another embodiment of thetechnology.

FIG. 6I is a plan view of an embodiment of a slot pattern for use in thesupport structure of FIG. 6H.

FIG. 6J is a plan view of a slot pattern for use with a treatment deviceconfigured in accordance with an embodiment of the technology.

FIGS. 6K and 6L illustrate deformed slots of the support structure ofFIG. 6H in a deployed state in accordance with an embodiment of thetechnology.

FIG. 6M is a plan view of a slot pattern for use with a treatment deviceconfigured in accordance with an embodiment of the technology.

FIG. 6N is a plan view of a slot pattern for use with a treatment deviceconfigured in accordance with an embodiment of the technology.

FIG. 6O is a schematic illustration of a portion of a treatment devicehaving a support structure including the slot pattern of FIG. 6N in adeployed state within a renal artery of a patient.

FIG. 7A is a plan view of a hole pattern for use with a treatment deviceconfigured in accordance with an embodiment of the technology.

FIG. 7B is a perspective view of a distal portion of a treatment deviceincluding a flexible region having the hole pattern of FIG. 7A in adelivery state outside a patient.

FIG. 8A is a broken perspective view in partial section of a treatmentdevice including the slot pattern of FIG. 6I configured in accordancewith an embodiment of the technology.

FIGS. 8B-8D illustrate various configurations of a distal end of asupport structure configured in accordance with embodiments of thepresent technology.

FIG. 9A illustrates a treatment device configured in accordance with anembodiment of the present technology in a deployed state (e.g., expandedconfiguration) outside a patient.

FIG. 9B illustrates the treatment device of FIG. 9A in a delivery state(e.g., low-profile or collapsed configuration).

FIG. 9C illustrates another embodiment of a treatment device configuredin accordance with an embodiment of the present technology in a deployedstate.

FIG. 9D illustrates yet another embodiment of a treatment device in adelivery state.

FIG. 9E illustrates the device of FIG. 9D in a deployed state.

FIG. 10A is broken plan view of another treatment device in a deliverystate outside a patient in accordance with an embodiment of thetechnology.

FIG. 10B is a detailed view of a distal portion of the device of FIG.10A in a deployed state.

FIG. 11A is a broken side view in part section of a treatment device ina delivery state in accordance with another embodiment of thetechnology.

FIG. 11B is a broken side view in part section of the treatment deviceof FIG. 11A in a deployed state.

FIG. 11C is a longitudinal cross-sectional view of a handle assembly foruse in the device of FIG. 11A in accordance with an embodiment of thepresent technology.

FIG. 11D is a longitudinal cross-sectional view of another handleassembly for use in the device of FIG. 11A in accordance with anembodiment of the present technology.

FIG. 12A is a side view of a distal portion of a treatment device in adelivery state (e.g., low-profile or collapsed configuration) outside apatient in accordance with an embodiment of the present technology.

FIG. 12B is a side view of the distal portion of the treatment device ofFIG. 12B in a deployed state (e.g., expanded configuration) outside thepatient.

FIG. 13A is a broken side view in part section of a treatment device ina delivery state in accordance an embodiment of the present technology.

FIG. 13B is a broken side view in part section of the embodiment of FIG.13A in a deployed state within a renal artery.

FIG. 14A is a broken longitudinal cross-sectional view of anotherembodiment of a treatment device in a delivery state in accordance anembodiment of the present technology.

FIG. 14B is a broken side view in part section of the embodiment of FIG.14A in a deployed state within a renal artery.

FIG. 14C is a longitudinal cross-sectional view of a distal portion ofanother embodiment of a treatment device in a delivery state inaccordance an embodiment of the present technology.

FIG. 14D is a broken longitudinal cross-sectional view of the embodimentof FIG. 14C in a deployed state within a renal artery.

FIG. 15A is a longitudinal cross-sectional view of a distal portion ofanother embodiment of a treatment device in a delivery state inaccordance an embodiment of the present technology.

FIG. 15B is a broken side view in part section of the embodiment of FIG.15A in a deployed state within a renal artery.

FIG. 16A is a cross-sectional view of one embodiment a treatment devicein a delivery state within a patient's renal artery in accordance anembodiment of the present technology.

FIG. 16B is a cross-sectional view of one embodiment a treatment devicein a deployed state within a patient's renal artery in accordance anembodiment of the present technology.

FIG. 17A is a broken side view in part section of a distal portion arapid-exchange type of a treatment device configured in accordance anembodiment of the present technology.

FIG. 17B is a broken side view in part section of a distal portion of arapid-exchange type of a treatment device in a delivery state inaccordance an embodiment of the present technology.

FIG. 17C is a broken side view of a distal portion of the treatmentdevice of FIG. 17B in a deployed state.

FIG. 17C is a broken side view in part section of a distal portion ofanother embodiment of a rapid-exchange type of a treatment device inaccordance an embodiment of the present technology.

FIG. 17D is a broken side view in part section of a distal portion ofanother rapid-exchange type of a treatment device in accordance anembodiment of the present technology.

FIG. 17E is a broken side view in part section of a distal portion ofyet another embodiment of a rapid-exchange type of a treatment device inaccordance an embodiment of the present technology.

FIG. 18 is an illustration of theoretical blood flow in a renal arteryin accordance with an embodiment of the technology.

FIG. 19A is a cross-sectional view of a treatment assembly including afluid redirecting element within a renal artery in accordance with anembodiment of the present technology.

FIG. 19B is a side view of a support structure with a schematicillustration of a fluid redirecting element in a delivery state (e.g.,low-profile or collapsed configuration) outside a patient in accordancewith an embodiment of the present technology.

FIG. 20 is a graph depicting an energy delivery algorithm that may beused in conjunction with the system of FIG. 1 in accordance with anembodiment of the technology.

FIGS. 21 and 22 are block diagrams illustrating algorithms forevaluating a treatment in accordance with embodiments of the presenttechnology.

FIG. 23 is a block diagram illustrating an algorithm for providingoperator feedback upon occurrence of a high temperature condition inaccordance with an embodiment of the present technology.

FIG. 24 is a block diagram illustrating an algorithm for providingoperator feedback upon occurrence of a high impedance condition inaccordance with an embodiment of the present technology.

FIG. 25 is a block diagram illustrating an algorithm for providingoperator feedback upon occurrence of a high degree of vesselconstriction in accordance with an embodiment of the present technology.

FIG. 26A is a block diagram illustrating an algorithm for providingoperator feedback upon occurrence of an abnormal heart rate condition inaccordance with an embodiment of the present technology.

FIG. 26B is a block diagram illustrating an algorithm for providingoperator feedback upon occurrence of a low blood flow condition inaccordance with an embodiment of the present technology.

FIGS. 27A and 27B are screen shots illustrating representative generatordisplay screens configured in accordance with aspects of the presenttechnology.

FIG. 28 is an illustration of a kit containing packaged components ofthe system of FIG. 1 in accordance with an embodiment of the technology.

FIG. 29 is a conceptual illustration of the sympathetic nervous system(SNS) and how the brain communicates with the body via the SNS.

FIG. 30 is an enlarged anatomic view of nerves innervating a left kidneyto form the renal plexus surrounding the left renal artery.

FIGS. 31A and 31B provide anatomic and conceptual views of a human body,respectively, depicting neural efferent and afferent communicationbetween the brain and kidneys.

FIGS. 32A and 32B are, respectively, anatomic views of the arterial andvenous vasculatures of a human.

DETAILED DESCRIPTION

The present technology is directed to apparatuses, systems, and methodsfor achieving electrically- and/or thermally-induced renalneuromodulation (i.e., rendering neural fibers that innervate the kidneyinert or inactive or otherwise completely or partially reduced infunction) by percutaneous transluminal intravascular access. Inparticular, embodiments of the present technology relate to apparatuses,systems, and methods that incorporate a catheter treatment device havinga multi-electrode array movable between a delivery or low-profile state(e.g., a generally straight shape) and a deployed state (e.g., aradially expanded, generally helical shape). The electrodes or energydelivery elements carried by the array are configured to deliver energy(e.g., electrical energy, radio frequency (RF) electrical energy, pulsedelectrical energy, thermal energy) to a renal artery after beingadvanced via catheter along a percutaneous transluminal path (e.g., afemoral artery puncture, an iliac artery and the aorta, a radial artery,or another suitable intravascular path). The multi-electrode array issized and shaped so that the electrodes or energy delivery elementscontact an interior wall of the renal artery when the array is in thedeployed (e.g., helical) state within the renal artery. In addition, thehelical shape of the deployed array allows blood to flow through thehelix, which is expected to help prevent occlusion of the renal arteryduring activation of the energy delivery element. Further, blood flow inand around the array may cool the associated electrodes and/or thesurrounding tissue. In some embodiments, cooling the energy deliveryelements allows for the delivery of higher power levels at lowertemperatures than may be reached without cooling. This feature isexpected to help create deeper and/or larger lesions during therapy,reduce intimal surface temperature, and/or allow longer activation timeswith reduced risk of overheating during treatment.

Specific details of several embodiments of the technology are describedbelow with reference to FIGS. 1-32B. Although many of the embodimentsare described below with respect to devices, systems, and methods forintravascular modulation of renal nerves using multi-electrode arrays,other applications and other embodiments in addition to those describedherein are within the scope of the technology. Additionally, severalother embodiments of the technology can have different configurations,components, or procedures than those described herein. A person ofordinary skill in the art, therefore, will accordingly understand thatthe technology can have other embodiments with additional elements, orthe technology can have other embodiments without several of thefeatures shown and described below with reference to FIGS. 1-32B.

As used herein, the terms “distal” and “proximal” define a position ordirection with respect to the treating clinician or clinician's controldevice (e.g., a handle assembly). “Distal” or “distally” are a positiondistant from or in a direction away from the clinician or clinician'scontrol device. “Proximal” and “proximally” are a position near or in adirection toward the clinician or clinician's control device.

I. Renal Neuromodulation

Renal neuromodulation is the partial or complete incapacitation or othereffective disruption of nerves innervating the kidneys. In particular,renal neuromodulation comprises inhibiting, reducing, and/or blockingneural communication along neural fibers (i.e., efferent and/or afferentnerve fibers) innervating the kidneys. Such incapacitation can belong-term (e.g., permanent or for periods of months, years, or decades)or short-term (e.g., for periods of minutes, hours, days, or weeks).Renal neuromodulation is expected to efficaciously treat severalclinical conditions characterized by increased overall sympatheticactivity, and in particular conditions associated with centralsympathetic over stimulation such as hypertension, heart failure, acutemyocardial infarction, metabolic syndrome, insulin resistance, diabetes,left ventricular hypertrophy, chronic and end stage renal disease,inappropriate fluid retention in heart failure, cardio-renal syndrome,and sudden death. The reduction of afferent neural signals contributesto the systemic reduction of sympathetic tone/drive, and renalneuromodulation is expected to be useful in treating several conditionsassociated with systemic sympathetic over activity or hyperactivity.Renal neuromodulation can potentially benefit a variety of organs andbodily structures innervated by sympathetic nerves. For example, areduction in central sympathetic drive may reduce insulin resistancethat afflicts patients with metabolic syndrome and Type II diabetics.Additionally, osteoporosis can be sympathetically activated and mightbenefit from the downregulation of sympathetic drive that accompaniesrenal neuromodulation. A more detailed description of pertinent patientanatomy and physiology is provided in Section IX below.

Various techniques can be used to partially or completely incapacitateneural pathways, such as those innervating the kidney. The purposefulapplication of energy (e.g., electrical energy, thermal energy) totissue by energy delivery element(s) can induce one or more desiredthermal heating effects on localized regions of the renal artery andadjacent regions of the renal plexus RP, which lay intimately within oradjacent to the adventitia of the renal artery. The purposefulapplication of the thermal heating effects can achieve neuromodulationalong all or a portion of the renal plexus RP.

The thermal heating effects can include both thermal ablation andnon-ablative thermal alteration or damage (e.g., via sustained heatingand/or resistive heating). Desired thermal heating effects may includeraising the temperature of target neural fibers above a desiredthreshold to achieve non-ablative thermal alteration, or above a highertemperature to achieve ablative thermal alteration. For example, thetarget temperature can be above body temperature (e.g., approximately37° C.) but less than about 45° C. for non-ablative thermal alteration,or the target temperature can be about 45° C. or higher for the ablativethermal alteration.

More specifically, exposure to thermal energy (heat) in excess of a bodytemperature of about 37° C., but below a temperature of about 45° C.,may induce thermal alteration via moderate heating of the target neuralfibers or of vascular structures that perfuse the target fibers. Incases where vascular structures are affected, the target neural fibersare denied perfusion resulting in necrosis of the neural tissue. Forexample, this may induce non-ablative thermal alteration in the fibersor structures. Exposure to heat above a temperature of about 45° C., orabove about 60° C., may induce thermal alteration via substantialheating of the fibers or structures. For example, such highertemperatures may thermally ablate the target neural fibers or thevascular structures. In some patients, it may be desirable to achievetemperatures that thermally ablate the target neural fibers or thevascular structures, but that are less than about 90° C., or less thanabout 85° C., or less than about 80° C., and/or less than about 75° C.Regardless of the type of heat exposure utilized to induce the thermalneuromodulation, a reduction in renal sympathetic nerve activity(“RSNA”) is expected.

II. Selected Embodiments of Catheter Apparatuses Having Multi-ElectrodeArrays

FIG. 1 illustrates a renal neuromodulation system 10 (“system 10”)configured in accordance with an embodiment of the present technology.The system 10 includes an intravascular treatment device 12 operablycoupled to an energy source or energy generator 26. In the embodimentshown in FIG. 1, the treatment device 12 (e.g., a catheter) includes anelongated shaft 16 having a proximal portion 18, a handle 34 at aproximal region of the proximal portion 18, and a distal portion 20extending distally relative to the proximal portion 18. The treatmentdevice 12 further includes a therapeutic assembly or treatment section21 at the distal portion 20 of the shaft 16. As explained in furtherdetail below, the therapeutic assembly 21 can include an array of two ormore electrodes or energy delivery elements 24 configured to bedelivered to a renal blood vessel (e.g., a renal artery) in alow-profile configuration. Upon delivery to the target treatment sitewithin the renal blood vessel, the therapeutic assembly 21 is furtherconfigured to be deployed into an expanded state (e.g., a generallyhelical or spiral configuration) for delivering energy at the treatmentsite and providing therapeutically-effective electrically- and/orthermally-induced renal neuromodulation. Alternatively, the deployedstate may be non-helical provided that the deployed state delivers theenergy to the treatment site. In some embodiments, the therapeuticassembly 21 may be placed or transformed into the deployed state orarrangement via remote actuation, e.g., via an actuator 36, such as aknob, pin, or lever carried by the handle 34. In other embodiments,however, the therapeutic assembly 21 may be transformed between thedelivery and deployed states using other suitable mechanisms ortechniques.

The proximal end of the therapeutic assembly 21 is carried by or affixedto the distal portion 20 of the elongated shaft 16. A distal end of thetherapeutic assembly 21 may terminate the treatment device 12 with, forexample, an atraumatic rounded tip or cap. Alternatively, the distal endof the therapeutic assembly 21 may be configured to engage anotherelement of the system 10 or treatment device 12. For example, the distalend of the therapeutic assembly 21 may define a passageway for engaginga guide wire (not shown) for delivery of the treatment device usingover-the-wire (“OTW”) or rapid exchange (“RX”) techniques. Furtherdetails regarding such arrangements are described below with referenceto FIGS. 9A-17E.

The energy source or energy generator 26 (e.g., a RF energy generator)is configured to generate a selected form and magnitude of energy fordelivery to the target treatment site via the energy delivery elements24. The energy generator 26 can be electrically coupled to the treatmentdevice 12 via a cable 28. At least one supply wire (not shown) passesalong the elongated shaft 16 or through a lumen in the elongated shaft16 to the energy delivery elements 24 and transmits the treatment energyto the energy delivery elements 24. In some embodiments, each energydelivery element 24 includes its own supply wire. In other embodiments,however, two or more energy delivery elements 24 may be electricallycoupled to the same supply wire. A control mechanism, such as foot pedal32, may be connected (e.g., pneumatically connected or electricallyconnected) to the energy generator 26 to allow the operator to initiate,terminate and, optionally, adjust various operational characteristics ofthe generator, including, but not limited to, power delivery. The system10 may also include a remote control device (not shown) that can bepositioned in a sterile field and operably coupled to the energydelivery elements 24. The remote control device is configured to allowfor selectively turning on/off the electrodes. In other embodiments, theremote control device may be built into the handle assembly 34. Theenergy generator 26 can be configured to deliver the treatment energyvia an automated control algorithm 30 and/or under the control of theclinician. In addition, the energy generator 26 may include one or moreevaluation or feedback algorithms 31 to provide feedback to theclinician before, during, and/or after therapy. Further detailsregarding suitable control algorithms and evaluation/feedback algorithmsare described below with reference to FIGS. 20-27.

In some embodiments, the system 10 may be configured to provide deliveryof a monopolar electric field via the energy delivery elements 24. Insuch embodiments, a neutral or dispersive electrode 38 may beelectrically connected to the energy generator 26 and attached to theexterior of the patient (as shown in FIG. 2). Additionally, one or moresensors (not shown), such as one or more temperature (e.g.,thermocouple, thermistor, etc.), impedance, pressure, optical, flow,chemical or other sensors, may be located proximate to or within theenergy delivery elements 24 and connected to one or more supply wires(not shown). For example, a total of two supply wires may be included,in which both wires could transmit the signal from the sensor and onewire could serve dual purpose and also convey the energy to the energydelivery elements 24. Alternatively, a different number of supply wiresmay be used to transmit energy to the energy delivery elements 24.

The energy generator 26 may be part of a device or monitor that mayinclude processing circuitry, such as a microprocessor, and a display.The processing circuitry may be configured to execute storedinstructions relating to the control algorithm 30. The monitor may beconfigured to communicate with the treatment device 12 (e.g., via cable28) to control power to the energy delivery elements 24 and/or to obtainsignals from the energy delivery elements 24 or any associated sensors.The monitor may be configured to provide indications of power levels orsensor data, such as audio, visual or other indications, or may beconfigured to communicate the information to another device. Forexample, the energy generator 26 may also be configured to be operablycoupled to a catheter lab screen or system for displaying treatmentinformation.

FIG. 2 (with additional reference to FIG. 30) illustrates modulatingrenal nerves with an embodiment of the system 10. The treatment device12 provides access to the renal plexus RP through an intravascular pathP, such as a percutaneous access site in the femoral (illustrated),brachial, radial, or axillary artery to a targeted treatment site withina respective renal artery RA. As illustrated, a section of the proximalportion 18 of the shaft 16 is exposed externally of the patient. Bymanipulating the proximal portion 18 of the shaft 16 from outside theintravascular path P, the clinician may advance the shaft 16 through thesometimes tortuous intravascular path P and remotely manipulate thedistal portion 20 of the shaft 16. Image guidance, e.g., computedtomography (CT), fluoroscopy, intravascular ultrasound (IVUS), opticalcoherence tomography (OCT), or another suitable guidance modality, orcombinations thereof, may be used to aid the clinician's manipulation.Further, in some embodiments, image guidance components (e.g., IVUS,OCT) may be incorporated into the treatment device 12 itself. After thetherapeutic assembly 21 is adequately positioned in the renal artery RA,it can be radially expanded or otherwise deployed using the handle 34 orother suitable means until the energy delivery elements 24 are in stablecontact with the inner wall of the renal artery RA. The purposefulapplication of energy from the energy delivery elements 24 is thenapplied to tissue to induce one or more desired neuromodulating effectson localized regions of the renal artery and adjacent regions of therenal plexus RP, which lay intimately within, adjacent to, or in closeproximity to the adventitia of the renal artery RA. The purposefulapplication of the energy may achieve neuromodulation along all or atleast a portion of the renal plexus RP.

The neuromodulating effects are generally a function of, at least inpart, power, time, contact between the energy delivery elements 24 andthe vessel wall, and blood flow through the vessel. The neuromodulatingeffects may include denervation, thermal ablation, and non-ablativethermal alteration or damage (e.g., via sustained heating and/orresistive heating). Desired thermal heating effects may include raisingthe temperature of target neural fibers above a desired threshold toachieve non-ablative thermal alteration, or above a higher temperatureto achieve ablative thermal alteration. For example, the targettemperature may be above body temperature (e.g., approximately 37° C.)but less than about 45° C. for non-ablative thermal alteration, or thetarget temperature may be about 45° C. or higher for the ablativethermal alteration. Desired non-thermal neuromodulation effects mayinclude altering the electrical signals transmitted in a nerve.

In some embodiments, the energy delivery elements 24 of the therapeuticassembly 21 may be proximate to, adjacent to, or carried by (e.g.,adhered to, threaded over, wound over, and/or crimped to) a supportstructure 22. The proximal end of the support structure 22 is preferablycoupled to the distal portion 20 of the elongated shaft 16 via acoupling (not shown). The coupling may be an integral component of theelongated shaft 16 (i.e., may not be a separate piece) or the couplingmay be a separate piece such as a collar (e.g., a radiopaque band)wrapped around an exterior surface of the elongated shaft 16 to securethe support structure 22 to the elongated shaft 16. In otherembodiments, however, the support structure 22 may be associated withthe elongated shaft 16 using another arrangement and/or differentfeatures.

In still another embodiment, the energy delivery elements 24 may form ordefine selected portions of, or the entirety of, the support structure22 itself. That is, as is described in further detail below, the supportstructure 22 may be capable of delivering energy. Moreover, although insome embodiments the therapeutic assembly 21 may function with a singleenergy delivery element, it will be appreciated that the therapeuticassembly 21 preferably includes a plurality of energy delivery elements24 associated with or defining the support structure 22. When multipleenergy delivery elements 24 are provided, the energy delivery elements24 may deliver power independently (i.e., may be used in a monopolarfashion), either simultaneously, selectively, or sequentially, and/ormay deliver power between any desired combination of the elements (i.e.,may be used in a bipolar fashion). Furthermore, the clinician optionallymay choose which energy delivery element(s) 24 are used for powerdelivery in order to form highly customized lesion(s) within the renalartery having a variety of shapes or patterns.

FIG. 3A is a cross-sectional view illustrating one embodiment of thedistal portion 20 of the shaft 16 and the therapeutic assembly 21 in adelivery state (e.g., low-profile or collapsed configuration) within arenal artery RA, and FIGS. 3B and 3C illustrate the therapeutic assembly21 in a deployed state (e.g., expanded or helical configuration) withinthe renal artery. Referring first to FIG. 3A, the collapsed or deliveryarrangement of the therapeutic assembly 21 defines a low profile aboutthe longitudinal axis A-A of the assembly such that a transversedimension of the therapeutic assembly 21 is sufficiently small to definea clearance distance between an arterial wall 55 and the treatmentdevice 12. The delivery state facilitates insertion and/or removal ofthe treatment device 12 and, if desired, repositioning of thetherapeutic assembly 21 within the renal artery RA.

In the collapsed configuration, for example, the geometry of the supportstructure 22 facilitates movement of the therapeutic assembly 21 througha guide catheter 90 to the treatment site in the renal artery RA.Moreover, in the collapsed configuration, the therapeutic assembly 21 issized and shaped to fit within the renal artery RA and has a diameterthat is less than a renal artery inner diameter 52 and a length (from aproximal end of the therapeutic assembly 21 to a distal end of thetherapeutic assembly 21) that is less than a renal artery length 54.Further, as described in greater detail below, the geometry of thesupport structure 22 is also arranged to define (in the delivery state)a minimum transverse dimension about its central axis that is less thanthe renal artery inner diameter 52 and a maximum length in the directionof the central axis that is preferably less than the renal artery length54. In one embodiment, for example, the minimum diameter of thetherapeutic assembly 21 is approximately equal to the interior diameterof the elongated shaft 16.

The distal portion 20 of the shaft 16 may flex in a substantial fashionto gain entrance into a respective left/right renal artery by followinga path defined by a guide catheter, a guide wire, or a sheath. Forexample, the flexing of distal portion 20 may be imparted by the guidecatheter 90, such as a renal guide catheter with a preformed bend nearthe distal end that directs the shaft 16 along a desired path, from thepercutaneous insertion site to the renal artery RA. In anotherembodiment, the treatment device 12 may be directed to the treatmentsite within the renal artery RA by engaging and tracking a guide wire(e.g., guide wire 66 of FIG. 2) that is inserted into the renal arteryRA and extends to the percutaneous access site. In operation, the guidewire is preferably first delivered into the renal artery RA and theelongated shaft 16 comprising a guide wire lumen is then passed over theguide wire into the renal artery RA. In some guide wire procedures, atubular delivery sheath 1291 (described in greater detail below withreference to FIGS. 16A and 16B) is passed over the guide wire (i.e., thelumen defined by the delivery sheath slides over the guide wire) intothe renal artery RA. Once the delivery sheath 1291 (FIG. 16A) is placedin the renal artery RA, the guide wire may be removed and exchanged fora treatment catheter (e.g., treatment device 12) that may be deliveredthrough the delivery sheath 1291 into the renal artery RA. Furthermore,in some embodiments, the distal portion 20 can be directed or “steered”into the renal artery RA via the handle assembly 34 (FIGS. 1 and 2), forexample, by an actuatable element 36 or by another control element. Inparticular, the flexing of the elongated shaft 16 may be accomplished asprovided in U.S. patent application Ser. No. 12/545,648, “Apparatus,Systems, and Methods for achieving Intravascular, Thermally-InducedRenal Neuromodulation” to Wu et al., which is incorporated herein byreference in its entirety. Alternatively, or in addition, the treatmentdevice 12 and its distal portion 20 may be flexed by being insertedthrough a steerable guide catheter (not shown) that includes a preformedor steerable bend near its distal end that can be adjusted or re-shapedby manipulation from the proximal end of the guide catheter.

The maximum outer dimension (e.g., diameter) of any section of thetreatment device 12, including elongated shaft 16 and the energydelivery elements 24 of the therapeutic assembly 21 can be defined by aninner diameter of the guide catheter 90 through which the device 12 ispassed. In one particular embodiment, for example, an 8 French guidecatheter having, for example, an inner diameter of approximately 0.091inch (2.31 mm) may be used as a guide catheter to access the renalartery. Allowing for a reasonable clearance tolerance between the energydelivery elements 24 and the guide catheter, the maximum outer dimensionof the therapeutic assembly 21 is generally less than or equal toapproximately 0.085 inch (2.16 mm). For a therapeutic assembly having asubstantially helical support structure for carrying the energy deliveryelements 24, the expanded or helical configuration preferably defines amaximum width of less than or equal to approximately 0.085 inch (2.16mm). However, use of a smaller 5 French guide catheter may require theuse of smaller outer diameters along the treatment device 12. Forexample, a therapeutic assembly 21 having a helical support structure 22that is to be routed within a 5 French guide catheter preferably has anouter dimension or maximum width of no greater than about 0.053 inch(1.35 mm). In still other embodiments, it may be desirable to have atherapeutic assembly 21 with a maximum width substantially under 0.053inch (1.35 mm) provided there is sufficient clearance between the energydelivery elements and the guide catheter. Moreover, in some embodimentsit may be desirable to have an arrangement in which the guide catheterand the therapeutic assembly 21 define a ratio of diameters of about1.5:1. In another example, the helical structure and energy deliveryelement 24 that are to be delivered within a 6 French guide catheterwould have an outer dimension of no great than 0.070 inch (1.78 mm). Instill further examples, other suitable guide catheters may be used, andouter dimensions and/or arrangements of the treatment device 12 can varyaccordingly.

After locating the therapeutic assembly 21 at the distal portion 20 ofthe shaft 16 in the renal artery RA, the therapeutic assembly 21 istransformed from its delivery state to its deployed state or deployedarrangement. The transformation may be initiated using an arrangement ofdevice components as described herein with respect to the particularembodiments and their various modes of deployment. As described ingreater detail below and in accordance with one or more embodiments ofthe present technology, the therapeutic assembly may be deployed by acontrol member, such as for example a pull- or tension-wire, guide wire,shaft or stylet engaged internally or externally with the supportstructure of the therapeutic assembly to apply a deforming or shapingforce to the assembly to transform it into its deployed state.Alternatively, the therapeutic assembly 21 may be self expanding ordeploying such that removal of a radial restraint results in deploymentof the assembly. Further, the modality used to transform the therapeuticassembly 21 from the delivery state into the deployed state may, in mostembodiments, be reversed to transform the therapeutic assembly 21 backto the delivery state from the deployed state.

Further manipulation of the support structure 22 and the energy deliveryelements 24 within the respective renal artery RA establishes appositionof the energy delivery elements 24 against the tissue along an interiorwall of the respective renal artery RA. For example, as shown in FIGS.3B and 3C, the therapeutic assembly 21 is expanded within the renalartery RA such that the energy delivery elements 24 are in contact withthe renal artery wall 55. In some embodiments, manipulation of thedistal portion 20 will also facilitate contact between the energydelivery elements 24 and the wall of the renal artery. Embodiments ofthe support structures described herein (e.g., the support structure 22)are expected to ensure that the contact force between the renal arteryinner wall 55 and the energy delivery elements 24 does not exceed amaximum value. In addition, the support structure 22 or other suitablesupport structures described herein preferably provide for a consistentcontact force against the arterial wall 55 that may allow for consistentlesion formation.

The alignment may also include alignment of geometrical aspects of theenergy delivery elements 24 with the renal artery wall 55. For example,in embodiments in which the energy delivery elements 24 have acylindrical shape with rounded ends, alignment may include alignment ofthe longitudinal surface of the individual energy delivery elements 24with the artery wall 55. In another example, an embodiment may compriseenergy delivery elements 24 having a structured shape or inactivesurface, and alignment may include aligning the energy delivery elements24 such that the structured shape or inactive surface is not in contactwith the artery wall 55.

As best seen in FIGS. 3B and 3C, in the deployed state, the therapeuticassembly 21 defines a substantially helical support structure 22 incontact with the renal artery wall 55 along a helical path. Oneadvantage of this arrangement is that pressure from the helicalstructure can be applied to a large range of radial directions withoutapplying pressure to a circumference of the vessel. Thus, thehelically-shaped therapeutic assembly 21 is expected to provide stablecontact between the energy delivery elements 24 and the artery wall 55when the wall moves in any direction. Furthermore, pressure applied tothe vessel wall 55 along a helical path is less likely to stretch ordistend a circumference of a vessel that could thereby cause injury tothe vessel tissue. Still another feature of the expanded helicalstructure is that it may contact the vessel wall in a large range ofradial directions and maintain a sufficiently open lumen in the vesselallowing blood to flow through the helix during therapy.

As best seen in FIG. 3B, in the deployed state, the support structure 22defines a maximum axial length of the therapeutic assembly 21 that isapproximately equal to or less than a renal artery length 54 of a mainrenal artery (i.e., a section of a renal artery proximal to abifurcation). Because this length can vary from patient to patient, itis envisioned that the deployed helical-shaped support structure 22 maybe fabricated in different sizes (e.g., with varying lengths L and/ordiameters D as shown in FIG. 4A) that may be appropriate for differentpatients. Referring to FIGS. 3B and 3C, in the deployed state, thehelical-shaped therapeutic assembly 21 provides for circumferentiallydiscontinuous contact between the energy delivery elements 24 and theinner wall 55 of the renal artery RA. That is, the helical path maycomprise a partial arc (i.e., <360°), a complete arc (i.e., 360°) or amore than complete arc (i.e., >360°) along the inner wall of a vesselabout the longitudinal axis of the vessel. In some embodiments, however,the arc is not substantially in one plane normal to the central axis ofthe artery, but instead preferably defines an obtuse angle with thecentral axis of the artery.

A. The Helical Structure

FIG. 4A is a plan view of an embodiment of a therapeutic or treatmentassembly 21 for use with a treatment device (e.g., treatment device 12)in accordance with an embodiment of the technology, and FIG. 4B is anisometric view of the therapeutic assembly 21 of FIG. 4A. The energydelivery elements 24 depicted in FIGS. 4A and 4B are merely forillustrative purposes, and it will be appreciated that the treatmentassembly 21 can include a different number and/or arrangement of energydelivery elements 24.

As shown in FIGS. 4A and 4B, a helix may be characterized, at least inpart, by its overall diameter D, length L, helix angle α (an anglebetween a tangent line to the helix and its axis), pitch HP(longitudinal distance of one complete helix turn measured parallel toits axis), and number of revolutions (number of times the helixcompletes a 360° revolution about its axis).

In particular, the deployed or expanded configuration of the helix maybe characterized by its axial length L along the axis of elongation infree space, e.g., not restricted by a vessel wall or other structure. Asthe helical support structure 22 radially expands from its deliverystate, its diameter D increases and its length L decreases. That is,when the helical structure deploys, a distal end 22 a moves axiallytowards the proximal end 22 b (or vice versa). Accordingly, the deployedlength L is less than the unexpanded or delivery length. In certainembodiments, only one of the distal end portion 22 a or the proximal endportion 22 b of the support structure 22 is fixedly coupled to theelongated shaft 16 or an extension thereof. In other embodiments, thesupport structure 22 may be transformed to its deployed or expandedconfiguration by twisting the distal and proximal end portions 22 a and22 b relative to one another.

Referring to FIG. 4B, the deployed helically-shaped support structure 22optionally comprises a distal extension 26 a distal to the helicalportion that is relatively straight and may terminate with an atraumatic(e.g., rounded) tip 50. The distal extension 26 a including the tip 50may reduce the risk of injuring the blood vessel as the helicalstructure is expanding and/or as a delivery sheath is retracted, and mayfacilitate alignment of the helical structure in a vessel as it expands.In some embodiments, the distal extension 26 a is generally straight(but flexible) and has a length of less than about 40 mm (e.g., between2 mm and 10 mm). The tip 50 can be made from a polymer or metal that isfixed to the end of the structural element by adhesive, welding,crimping, over-molding, and/or solder. In other embodiments, the tip 50may be made from the same material as the structural element andfabricated into the tip 50 by machining or melting. In otherembodiments, the distal extension 26 a may have a differentconfiguration and/or features. For example, in some embodiments the tip50 may comprise an energy delivery element or a radiopaque marker.Further, the distal extension 26 a is an optional feature that may notbe included in all embodiments.

The helical structure may also optionally have a proximal extension 26 bthat is relatively straight compared to the helically shaped region ofthe support structure 22. The proximal extension 26 b, for example, maybe an extension of the support structure 22 and may have a lengthbetween 0 mm and 40 mm (e.g., between about 2 and 10 mm). Alternatively,the proximal extension 26 b may be comprised of a separate material(e.g., a polymer fiber) with more flexibility than the rest of thesupport structure 22. The proximal extension 26 b is configured toprovide a flexible connection between the helical region of the supportstructure 22 and the distal end of the elongated shaft 16 (FIG. 1). Thisfeature is expected to facilitate alignment of the deployed helicalsupport structure 22 with the vessel wall by reducing the forcetransferred from the elongated shaft 16 to the helical region of thehelical structure 22. This may be useful, for example, when theelongated shaft is biased toward a side of the vessel wall or if theelongated shaft moves relative to the vessel wall allowing the helicalstructure to remain positioned.

Referring back to FIGS. 4A and 4B together (and with reference to FIGS.3A and 3B), the dimensions of the deployed helically-shaped structure 22are influenced by its physical characteristics and its configuration(e.g., expanded vs. unexpanded), which in turn may be selected withrenal artery geometry in mind. For example, the axial length L of thedeployed helical structure may be selected to be no longer than apatient's renal artery (e.g., the length 54 of renal artery RA of FIGS.3A and 3B). For example, the distance between the access site and theostium of the renal artery (e.g., the distance from a femoral accesssite to the renal artery is typically about 40 cm to about 55 cm) isgenerally greater than the length of a renal artery from the aorta andthe most distal treatment site along the length of the renal artery,which is typically less than about 7 cm. Accordingly, it is envisionedthat the elongated shaft 16 (FIG. 1) is at least 40 cm and the helicalstructure is less than about 7 cm in its unexpanded length L. A lengthin an unexpanded configuration of no more than about 4 cm may besuitable for use in a large population of patients and provide a longcontact area when in an expanded configuration and, in some embodiments,provide a long region for placement of multiple energy deliveryelements; however, a shorter length (e.g., less than about 2 cm) in anunexpanded configuration may be used in patients with shorter renalarteries. The helical structure 22 may also be designed to work withtypical renal artery diameters. For example, the diameter 52 (FIG. 3A)of the renal artery RA may vary between about 2 mm and about 10 mm. In aparticular embodiment, the placement of the energy delivery elements 24on the helical structure 22 may be selected with regard to an estimatedlocation of the renal plexus RP relative to the renal artery RA.

In another specific embodiment, a section or support structure of thetherapeutic assembly 21, when allowed to fully deploy to anunconstrained configuration (i.e., outside of the body as shown in FIGS.4A and 4B), comprises a helical shape having a diameter D less thanabout 15 mm (e.g., about 12 mm, 10 mm, 8 mm, or 6 mm); a length L lessthan or equal to about 40 mm (e.g., less than about 25 mm, less thanabout 20 mm, less than about 15 mm); a helix angle α of between about20° and 75° (e.g., between about 35° and 55°); a range of revolutionsbetween 0.25 and 6 (e.g., between 0.75 and 2, between 0.75 and 1.25);and a pitch HP between about 5 mm and 20 mm (e.g., between about 7 mmand 13 mm). In another example, the therapeutic assembly 21 may beconfigured to expand radially from its delivery state with a diameterabout its central axis being approximately 10 mm to a delivery state inwhich the energy delivery elements 24 are in contact with the arterywall. The foregoing dimensions/angles are associated with specificembodiments of the technology, and it will be appreciated thattherapeutic assemblies configured in accordance with other embodimentsof the technology may have different arrangements and/or configurations.

In some embodiments, the deployed helically-shaped support structure 22may be generally cylindrical (i.e., a helical diameter can be generallyconsistent along a majority of its length). It is also contemplated,however, that the structure 22 may have variations such as a conicalhelical shape, a tapered structural element, clockwise orcounterclockwise pathway, consistent or varied pitch.

In one embodiment, the support structure 22 can include a solidstructural element, e.g., a wire, tube, coiled or braided cable. Thesupport structure 22 may be formed from biocompatible metals and/orpolymers, including polyethylene terephthalate (PET), polyamide,polyimide, polyethylene block amide copolymer, polypropylene, orpolyether ether ketone (PEEK) polymers. In some embodiments, the supportstructure 22 may be electrically nonconductive, electrically conductive(e.g., stainless steel, nitinol, silver, platinum,nickel-cobalt-chromium-molybdenum alloy), or a combination ofelectrically conductive and nonconductive materials. In one particularembodiment, for example, the support structure 22 may be formed of apre-shaped material, such as spring temper stainless steel or nitinol.Furthermore, in particular embodiments, the structure 22 may be formed,at least in part, from radiopaque materials that are capable of beingfluoroscopically imaged to allow a clinician to determine if thetreatment assembly 21 is appropriately placed and/or deployed in therenal artery. Radiopaque materials may include, for example, bariumsulfate, bismuth trioxide, bismuth subcarbonate, powdered tungsten,powdered tantalum, or various formulations of certain metals, includinggold and platinum, and these materials may be directly incorporated intostructural elements 22 or may form a partial or complete coating on thehelical structure 22.

Generally, the helical structure 22 may be designed to apply a desiredoutward radial force to the renal artery wall 55 (FIGS. 3A and 3B) wheninserted and expanded to contact the inner surface of the renal arterywall 55 (FIGS. 3A and 3B). The radial force may be selected to avoidinjury from stretching or distending the renal artery RA when thehelical structure 22 is expanded against the artery wall 55 within thepatient. Radial forces that may avoid injuring the renal artery RA yetprovide adequate stabilization force may be determined by calculatingthe radial force exerted on an artery wall by typical blood pressure.For example, a suitable radial force may be less than or equal to about300 mN/mm (e.g., less than 200 mN/mm). Factors that may influence theapplied radial force include the geometry and the stiffness of thesupport structure 22. In one particular embodiment, the supportstructure 22 is about 0.003-0.009 inch (0.08-0.23 mm) in diameter.Depending on the composition of the support structure 22, the structuralelement diameter may be selected to facilitate a desired conformabilityand/or radial force against the renal artery when expanded. For example,a support structure 22 formed from a stiffer material (e.g., metal) maybe thinner relative to a support structure 22 formed from a highlyflexible polymer to achieve similar flexibilities and radial forceprofiles. The outward pressure of the helical support structure 22 maybe assessed in vivo by an associated pressure transducer.

In addition, certain secondary processes, including heat treating andannealing may harden or soften the fiber material to affect strength andstiffness. In particular, for shape-memory alloys such as nitinol, thesesecondary processes may be varied to give the same starting materialdifferent final properties. For example, the elastic range or softnessmay be increased to impart improved flexibility. The secondaryprocessing of shape memory alloys influences the transition temperature,i.e., the temperature at which the structure exhibits a desired radialstrength and stiffness. In embodiments that employ shape memoryproperties, such as shape memory nitinol, this transition temperaturemay be set at normal body temperature (e.g., around 37° C.) or in arange between about 37° C. and 45° C. In other embodiments that comprisesuper elastic nitinol, a transition temperature can be well below bodytemperature, for example below 0° C. Alternatively, the helicalstructure may be formed from an elastic or super elastic material suchas nitinol that is thermally engineered into a desired helical shape.Alternatively, the helical structure 22 may be formed from multiplematerials such as one or more polymers and metals.

Referring back to FIGS. 3B and 3C together, it should be understood thatthe support structure 22 of the treatment assembly 21, when not insertedinto a patient, is capable of deploying to a maximum diameter that islarger than the diameter in its delivery state. Further, thehelically-shaped structure 22 may be sized so that the maximum diameteris larger than the lumen diameter 52 of the renal artery RA. Wheninserted into a patient and transformed to the deployed state, however,the helically-shaped structure 22 expands radially to span the renalartery lumen and, at its largest circumferential section, isapproximately or slightly less than (e.g., in embodiments in which theenergy delivery elements 24 fill some of the space) the diameter 52 ofthe renal artery RA. A slight amount of vessel distension may be causedwithout undue injury and the structure 22 may expand such that itslargest circumferential section is slightly more than the diameter 52 ofthe renal artery RA, or such that one or more energy delivery elements24 are slightly pressed into the wall 55 of the renal artery RA. Ahelically-shaped assembly or array that causes slight and non-injuriousdistension of an artery wall 55 may advantageously provide stablecontact force between the energy delivery elements 24 and the arterywall 55 and/or hold the energy delivery elements 24 in place even as theartery moves with respiratory motion and pulsing blood flow. Becausethis diameter 52 of the renal artery RA varies from patient to patient,the treatment assembly 21 may be capable of assuming a range ofdiameters between the delivery diameter and the maximum diameter.

As provided above, one feature of the deployed therapeutic assembly 21in the helical configuration is that the energy delivery elements 24associated with the helical structure may be placed into stable contactwith a vessel wall to reliably create consistent lesions. Further,multiple energy delivery elements 24 may be placed along the helicalstructure with appropriate spacing to achieve a desired lesionconfiguration within the target vessel. Another feature of severalembodiments of the therapeutic assembly 21 having the helicalconfiguration described above is that the assembly may be expanded tofit within a relatively wide range of different vessel diameters and/orwith various tortuosities.

B. Size and Configuration of the Energy Delivery Elements

It should be understood that the embodiments provided herein may be usedin conjunction with one or more energy delivery elements 24. Asdescribed in greater detail below, the deployed helically-shapedstructure carrying the energy delivery elements 24 is configured toprovide a therapeutic energy delivery to the renal artery without anyrepositioning. Illustrative embodiments of the energy delivery elements24 are shown in FIGS. 5A-5D. The energy delivery elements 24 associatedwith the helical structure 22 may be separate elements or may be anintegral part of the helical structure 22. In some patients, it may bedesirable to use the energy delivery element(s) 24 to create a singlelesion or multiple focal lesions that are spaced around thecircumference of the renal artery. A single focal lesion with desiredlongitudinal and/or circumferential dimensions, one or more full-circlelesions, multiple circumferentially spaced focal lesions at a commonlongitudinal position, spiral-shaped lesions, interrupted spirallesions, generally linear lesions, and/or multiple longitudinally spaceddiscrete focal lesions at a common circumferential positionalternatively or additionally may be created. In still furtherembodiments, the energy delivery elements 24 may be used to createlesions having a variety of other geometric shapes or patterns.

Depending on the size, shape, and number of the energy delivery elements24, the formed lesions may be spaced apart around the circumference ofthe renal artery and the same formed lesions also may be spaced apartalong the longitudinal axis of the renal artery. In particularembodiments, it is desirable for each formed lesion to cover at least10% of the vessel circumference to increase the probability of affectingthe renal plexus. Furthermore, to achieve denervation of the kidney, itis considered desirable for the formed lesion pattern, as viewed from aproximal or distal end of the vessel, to extend at least approximatelyall the way around the circumference of the renal artery. In otherwords, each formed lesion covers an arc of the circumference, and eachof the lesions, as viewed from an end of the vessel, abut or overlapadjacent or other lesions in the pattern to create either an actualcircumferential lesion or a virtually circumferential lesion. The formedlesions defining an actual circumferential lesion lie in a single planeperpendicular to a longitudinal axis of the renal artery. A virtuallycircumferential lesion is defined by multiple lesions that may not alllie in a single perpendicular plane, although more than one lesion ofthe pattern can be so formed. At least one of the formed lesionscomprising the virtually circumferential lesion is axially spaced apartfrom other lesions. In a non-limiting example, a virtuallycircumferential lesion can comprise six lesions created in a singlehelical pattern along the renal artery such that each lesion spans anarc extending along at least one sixth of the vessel circumference suchthat the resulting pattern of lesions completely encompasses the vesselcircumference when viewed from an end of the vessel. In other examples,however, a virtually circumferential lesion can comprise a differentnumber of lesions. It is also desirable that each lesion be sufficientlydeep to penetrate into and beyond the adventitia to thereby affect therenal plexus. However, lesions that are too deep (e.g., >5 mm) run therisk of interfering with non-target tissue and tissue structures (e.g.,a renal vein) so a controlled depth of energy treatment is alsodesirable.

As shown in FIGS. 4A and 4B, energy delivery elements 24 may bedistributed on the helical structure 22 in a desired arrangement. Forexample, the axial distances between the energy delivery elements 24 maybe selected so that the edges of the lesions formed by individual energydelivery elements 24 on the renal artery wall 55 are overlapping ornon-overlapping. One or both of the axial distances xx or yy may beabout 2 mm to about 1 cm. In a particular embodiment, the axialdistances xx or yy may be in the range of about 2 mm to about 5 mm. Inanother embodiment, the energy delivery elements 24 may be spaced apartabout 30 mm. In still another embodiment, the energy delivery elements24 are spaced apart about 11 mm. In yet another embodiment, the energydelivery elements 24 are spaced apart about 17.5 mm. Further, the axialdistance xx may be less than, about equal to, or greater than the axialdistance yy.

Spacing of energy delivery elements 24 may be characterized by a helicallength distance zz, that is, the distance between energy deliveryelements along the path of the helical structure 22. The helical lengthdistance zz may be chosen based on the size of lesions created by energydelivery elements 24 so the lesions either overlap or do not overlap. Insome embodiments, the energy delivery elements 24 are bothlongitudinally and circumferentially offset from one another. FIG. 4C,for example, is an end view of the helical structure 22 showing theangular offset or separation of the energy delivery elements 24 from oneanother around the circumference of the deployed helical structure 22.In particular, energy delivery element 24 c is offset from energydelivery element 24 a by angle 150 and offset from energy deliveryelement 24 b by angle 152. The offset angles may be selected such that,when energy is applied to the renal artery via energy delivery elements24 a, 24 b, and 24 c, the lesions may or may not overlapcircumferentially.

FIG. 4D is a side view of a vessel with formed lesions 340 thatcircumferentially and/or longitudinally overlap, but do not overlapalong a helical path. More specifically, lesions 340 can be formed byenergy delivery elements 24 to have a circumferential overlap 341 asviewed from one end of the vessel (e.g., FIG. 4C) and/or a longitudinaloverlap 342, but may not produce a helical length overlap, insteadforming a helical length gap 343. For example, energy delivery elements24 may take the form of electrodes for applying an electrical field ofRF energy to a vessel wall and be configured to produce lesions that areabout 5 mm in diameter with the electrodes spaced apart by helicallength distance of about 6 to 7 mm. Depending on the number andpositioning of the energy delivery elements 24, a helical lesion patternwith any suitable number of turns may be formed. As such, the treatmentdevice 12 may employ a single energy application to form a complexlesion pattern. It should be noted that the embodiments illustrated inFIGS. 4A-4C are exemplary, may be schematic in nature, may not correlateexactly to one another, and are shown only for the purposes ofclarifying certain aspects of the technology. As such, the number andspacing of energy delivery elements 24 are different in each of FIGS.4A-4C, and lesions formed by the illustrated embodiments may not createa sufficiently overlapping pattern to achieve a virtuallycircumferential lesion as described above, particularly when applyingenergy in only one deployment of the treatment assembly 21 withoutrepositioning.

Referring back to FIG. 3B, the individual energy delivery elements 24are connected to energy generator 26 (FIG. 1) and are sized andconfigured to contact an internal wall of the renal artery. In theillustrated embodiment, the energy delivery element 24 may be operatedin a monopolar or unipolar mode. In this arrangement, a return path forthe applied RF electric field is established, e.g., by an externaldispersive electrode (shown as element 38 in FIGS. 1 and 2), also calledan indifferent electrode or neutral electrode. The monopolar applicationof RF electric field energy serves to ohmically or resistively heattissue in the vicinity of the electrode. The application of the RFelectrical field thermally injures tissue. The treatment objective is tothermally induce neuromodulation (e.g., necrosis, thermal alteration orablation) in the targeted neural fibers. The thermal injury forms alesion in the vessel wall. Alternatively, a RF electrical field may bedelivered with an oscillating or pulsed intensity that does notthermally injure the tissue whereby neuromodulation in the targetednerves is accomplished by electrical modification of the nerve signals.

The active surface area of the energy delivery element 24 is defined asthe energy transmitting area of the element 24 that may be placed inintimate contact against tissue. Too much contact area between theenergy delivery element and the vessel wall may create unduly hightemperatures at or around the interface between the tissue and theenergy delivery element, thereby creating excessive heat generation atthis interface. This excessive heat may create a lesion that iscircumferentially too large. This may also lead to undesirable thermalapplication to the vessel wall. In some instances, too much contact canalso lead to small, shallow lesions. Too little contact between theenergy delivery element and the vessel wall may result in superficialheating of the vessel wall, thereby creating a lesion that is too small(e.g., <10% of vessel circumference) and/or too shallow.

The active surface area of contact (ASA) between the energy deliveryelement 24 and the inner vessel wall (e.g., renal artery wall 55) hasgreat bearing on the efficiency and control of the generation of athermal energy field across the vessel wall to thermally affect targetedneural fibers in the renal plexus. While the ASA of the energy deliveryelement is important to creating lesions of desirable size and depth,the ratio between the ASA and total surface area (TSA) of the energydelivery element 24 and electrode 46 is also important. The ASA to TSAratio influences lesion formation in two ways: (1) the degree ofresistive heating via the electric field, and (2) the effects of bloodflow or other convective cooling elements such as injected or infusedsaline. For example, an RF electric field causes lesion formation viaresistive heating of tissue exposed to the electric field. The higherthe ASA to TSA ratio (i.e., the greater the contact between theelectrode and tissue), the greater the resistive heating, e.g., thelarger the lesion that is formed. As discussed in greater detail below,the flow of blood over the non-contacting portion of the electrode (TSAminus ASA) provides conductive and convective cooling of the electrode,thereby carrying excess thermal energy away from the interface betweenthe vessel wall and electrode. If the ratio of ASA to TSA is too high(e.g., more than 50%), resistive heating of the tissue may be tooaggressive and not enough excess thermal energy is being carried away,resulting in excessive heat generation and increased potential forstenotic injury, thrombus formation and undesirable lesion size. If theratio of ASA to TSA is too low (e.g., 10%), then there is too littleresistive heating of tissue, thereby resulting in superficial heatingand smaller and shallower lesions. In a representative embodiment, theASA of the energy delivery elements 24 contacting tissue may beexpressed as

0.25 TSA≤ASA≤0.50 TSA

An ASA to TSA ratio of over 50% may still be effective without excessiveheat generation by compensating with a reduced power delivery algorithmand/or by using convective cooling of the electrode by exposing it toblood flow. As discussed further below, electrode cooling can beachieved by injecting or infusing cooling liquids such as saline (e.g.,room temperature saline or chilled saline) over the electrode and intothe blood stream.

Various size constraints for an energy delivery element 24 may beimposed for clinical reasons by the maximum desired dimensions of theguide catheter, as well as by the size and anatomy of the renal arterylumen itself. In some embodiments such as those shown in FIGS. 13 and25, the maximum outer diameter (or cross-sectional dimension fornon-circular cross-section) of the energy delivery element 24 may be thelargest diameter encountered along the length of the elongated shaft 16distal to the handle assembly 34. As previously discussed, for clinicalreasons, the maximum outer diameter (or cross-sectional dimension) ofthe energy delivery element 24 is constrained by the maximum innerdiameter of the guide catheter through which the elongated shaft 16 isto be passed through the intravascular path 14. Assuming that an 8French guide catheter (which has an inner diameter of approximately0.091 inch (2.31 mm)) is, from a clinical perspective, the largestdesired catheter to be used to access the renal artery, and allowing fora reasonable clearance tolerance between the energy delivery element 24and the guide catheter, the maximum diameter of the electrode 46 isconstrained to about 0.085 inch (2.16 mm). In the event a 6 French guidecatheter is used instead of an 8 French guide catheter, then the maximumdiameter of the energy delivery element 24 is constrained to about 0.070inch (1.78 mm), e.g., about 0.050 inch (1.27 mm). In the event a 5French guide catheter is used, then maximum diameter of the energydelivery element 24 is constrained to about 0.053 inch (1.35 mm).

Based upon these constraints and the aforementioned power deliveryconsiderations, the energy delivery element 24 may have an outerdiameter of from about 0.049 to about 0.051 inch (1.24 mm-1.30 mm). Theenergy delivery elements 24 also may have a minimum outer diameter ofabout 0.020 inch (0.51 mm) to provide sufficient cooling and lesionsize. In some embodiments, the energy delivery element 24 may have alength of about 1 mm to about 3 mm. In some embodiments in which theenergy delivery element 24 is a resistive heating element, the energydelivery element 24 have a maximum outer diameter from about 0.049 to0.051 inch (1.24 mm-1.30 mm) and a length of about 10 mm to 30 mm. Oneembodiment of energy delivery elements 24, for example, provides for amultiple array of 4-6 electrodes disposed about a support structure(e.g., a tubular structure). The energy delivery elements 24, forexample, may be gold electrodes or alternatively, platinum,platinum-iridium, or another suitable material. In one particularembodiment, the electrodes may measure about 0.030 inch ID×0.0325 ODinch×0.060 inch in length (0.76 mm×0.83 mm×1.52 mm). In still anotherparticular embodiment, the electrodes may measure 0.029 inch ID×0.033inch OD×0.060 inch length (0.72 mm×0.83 mm×1.52 mm). In yet anotherparticular embodiment, the electrodes may measure 0.038 inch ID×0.042inch OD×0.060 inch length (0.97 mm×1.07 mm×1.52 mm). Moreover, theelectrodes may be appropriately electrically insulated from the supportstructure with the supply wire array of each of the electrodes jacketedin a polymer so as to provide for a compact packaged electrode arrayassembly about the support structure 22.

In other embodiments, the outer diameter of the treatment device 12 maybe defined by the one or more energy delivery elements 24 and may befurther defined by elements such as e.g., control wire 168 as shown inFIG. 8A. For example, particular embodiments may be used with an 8French guide catheter and may comprise energy delivery element(s) 24with a diameter between about 0.049 to 0.053 inch (1.24 mm to 1.35 mm)and a control wire with a diameter between about 0.005 to 0.015 inch(0.13 mm to 0.38 mm) in diameter. In other embodiments, however, thearrangement and/or dimensions of the energy delivery elements 24 and/orcontrol wire may vary.

In certain embodiments, the helical structure 22 may be formed of anelectrically conductive material. For example, the helical structure 22may be made from nitinol wire, cable, or tube. As shown in FIG. 5E, wireleads 19 may connect the helical structure 22 to energy generator 26.The helical structure 22 forms a contact region with the renal arterywall and acts as the energy delivery element 24. In this configuration,the helical structure 22 is capable of producing a continuous helicallesion. A helical structure 22 that is configured to be an energydelivery element 24 may optionally comprise sensors 33 positioned on,in, and/or proximate to the helical structure 22 and may be electricallyconnected to supply wires 35.

In other embodiments, the electrically conductive helical structure 22is insulated at least in part. That is, the conductive helical structureis partially covered with an electrically insulating material and theuncovered portions of the helical structure 22 serve as one or moreconductive energy delivery elements 24. The energy delivery elements 24may be any size, shape, or number, and may be positioned relative to oneanother as provided herein.

Energy delivery element 24 may be configured to deliver thermal energy,i.e., to heat up and conduct thermal energy to tissue. For example,energy delivery elements may be an electrically resistive element suchas a thermistor or a coil made from electrically resistive wire so thatwhen electrical current is passed through the energy delivery elementheat is produced. An electrically resistive wire may be for example analloy such as nickel-chromium with a diameter for example between 48 and30 AWG. The resistive wire may be electrically insulated for examplewith polyimide enamel.

In certain embodiments, the energy delivery elements 24 may be angularlyrepositioned relative to the renal artery during treatment. Referringback to FIGS. 1 and 2, for example, this angular repositioning may beachieved by compressing the therapeutic assembly 21 and rotating theelongated shaft 16 of the treatment device 12 via the handle assembly34. In addition to the angular or circumferential repositioning of theenergy delivery elements 24, the energy delivery elements 24 optionallymay also be repositioned along the lengthwise or longitudinal dimensionof the renal artery. This longitudinal repositioning may be achieved,for example, by translating the elongated shaft 16 of treatment device12 via handle assembly 34, and may occur before, after, or concurrentwith angular repositioning of the energy delivery elements 24. Withreference to FIG. 3B, repositioning the energy delivery elements 24 inboth the longitudinal and angular dimensions places the energy deliveryelements 24 in contact with the interior wall 55 of the renal artery RAat a second treatment site for treating the renal plexus RP. Inoperation, energy may then be delivered via the energy delivery elements24 to form a second focal lesion at this second treatment site. Forembodiments in which multiple energy delivery elements 24 are associatedwith the helical structure, the initial treatment may result in two ormore lesions, and repositioning may allow additional lesions to becreated.

In certain embodiments, the lesions created via repositioning of thehelically-shaped support structure 22 are angularly and longitudinallyoffset from the initial lesion(s) about the angular and lengthwisedimensions of the renal artery RA, respectively. The composite lesionpattern created along the renal artery RA by the initial energyapplication and all subsequent energy applications after anyrepositioning of the energy delivery element(s) 24 may effectivelyresult in a discontinuous lesion (i.e., it is formed from multiple,longitudinally and angularly spaced treatment sites).

In an alternative embodiment, the energy delivery element 24 may be inthe form of an electrically conductive wire. As shown in FIG. 5D, forexample, a conductive wire 500 may be wound about the helical structure22 to form a coiled electrode 24′. The coiled electrode 24′ may provideincreased surface area for delivering energy. For example, the coiledelectrode 24′ may form a generally continuous helical lesion in a singleenergy application. The coiled electrode 24′ may be wound in any mannerabout the helical structure 22, depending on the desired lesion. Forexample, the coiled electrode 24′ may form a continuous path along alength of the helix or the coiled structure may form one or more shortdiscrete electrodes separated by non-conducting sections. In otherembodiments, portions of the coiled electrode 24′ may be positioned onthe helical structure to come in contact with the vessel wall when thehelical structure is expanded, while other portions of the coiledelectrode 24′ may be positioned away from the vessel wall when thehelical structure is expanded to allow lesions to be discontinuous.Further, in such an arrangement, regions of the coiled electrode 24′that do not contact the renal artery may contribute to cooling of theenergy delivery elements 24′, as described in greater detail below. Thepositioning and number of conductive portions forming the energydelivery elements 24′ may be selected according to a desired lesionpattern.

In the embodiments shown in FIGS. 5A and 5B, energy delivery elements 24preferably comprise metal electrodes with rounded ends and a lumen. Thenitinol helical support structure 22 is preferably electricallyinsulated (e.g., with PET) and the electrodes 24 are mounted over theinsulation. Supply wires 25 connect the electrodes to an energy source(not shown) and deliver energy (e.g., RF electrical current) to theelectrodes 24. The rounded ends reduce mechanical irritation to thevessel wall and provide a more consistent current density when energy isdelivered compared to electrodes with square or sharper ends. The energydelivery elements 24 may alternatively comprise other forms as noted,such as a coil electrode 24′ described above with reference to FIG. 5D.In another embodiment, the structural element 510 that forms the helicalstructure 22 may be the energy delivery element 24′ itself, as seen, forexample in FIG. 5C.

III. Selected Embodiments of Renal Denervation Systems

The representative embodiments provided herein include features that maybe combined with one another and with the features of other disclosedembodiments. In an effort to provide a concise description of theseembodiments, not all features of an actual implementation are describedin the specification. It should be appreciated that in the developmentof any such actual implementation, as in any engineering or designproject, numerous implementation-specific decisions should be made toachieve the developers' specific goals, such as compliance withsystem-related and business-related constraints, which may vary from oneimplementation to another.

FIG. 6A illustrates an embodiment of a treatment device 112 including anelongated shaft 116 having different mechanical and functional regionsconfigured in accordance with an embodiment of the technology. Theelongated shaft 116 of the treatment device 112, for example, includes adistal region with a therapeutic or treatment assembly 121 for deliveryand deployment at a renal artery site for treatment and, in particular,for renal denervation. Disposed at a proximal end of the elongated shaft116 is a handle assembly 134 for manipulation of the elongated shaft 116and the therapeutic assembly 121. More specifically, the handle assembly134 is configured with an actuator 136 (schematically shown) to providefor remote operation of a control member (e.g., control wire 168 of FIG.6E or 8A) for controlling or transforming the therapeutic assembly 121between a delivery state and a deployed state. Further details regardingsuitable handle assemblies may be found, for example, in U.S. patentapplication Ser. No. 12/759,641, “Handle Assemblies for IntravascularTreatment Devices and Associated System sand Methods” to Clark et al.,which is incorporated herein by reference in its entirety.

The treatment device 112 is configured to deliver the therapeuticassembly 121 to a treatment site in a delivery (e.g., low-profile) statein which the assembly 121 is substantially linear (e.g., straight) suchthat energy delivery elements (not shown) carried by a support structure122 of the treatment assembly 121 are substantially axially alignedalong the support member 122. Once located at the treatment site withinthe renal artery, the handle assembly 134 is operated for actuation of acontrol member that transforms the therapeutic assembly 121 from thedelivery state to a deployed state. In one embodiment, for example, thecontrol member comprises a control wire 168 (FIG. 8A) disposed within aninternal lumen of the tubular support structure 122. One end of thecontrol wire 168 may be affixed at or near the distal end of the supportstructure 122, and the opposite end of the control wire 168 terminateswithin the handle assembly 134. As mentioned previously, the handleassembly 134 is configured for manipulating the control wire 168 totransform the therapeutic assembly 121 between the delivery and thedeployed states. The tension in the control wire 168 provides for aproximally and axially directed force that acts on the support structure122. Under the influence of the tension force in the control wire 168and, in operation within a patient under the influence of a radialconstraint of the patient's renal arterial wall, the support structure122 deforms so as to deploy into the helical geometry to bring theenergy delivery elements into stable contact with the wall of the renalartery.

To provide for the desired deformation upon deployment, the supportstructure 122 may be a tubular member having a plurality of slots, cuts,through holes, and/or openings selectively formed or disposed about thesupport structure 122. The tubular support structure 122 may have anumber of features generally similar to the features of supportstructure 22 described above. For example, the support structure 122 maybe formed from biocompatible metals and/or polymers, including PET,polyamide, polyimide, polyethylene block amide copolymer, polypropylene,or PEEK polymers, and the slots are preferably laser cut into thetubular structure in a desired configuration. In particular embodiments,the support structure 122 may be electrically nonconductive,electrically conductive (e.g., stainless steel, nitinol, silver,platinum nickel-cobalt-chromium-molybdenum alloy), or a combination ofelectrically conductive and nonconductive materials. In one particularembodiment, the support structure 122 may be formed of a pre-shapedmaterial, such as spring temper stainless steel or nitinol. Moreover, insome embodiments the support structure 122 may be formed, at least inpart, from radiopaque materials that are capable of being imagedfluoroscopically to allow a clinician to determine if the supportstructure 122 is appropriately placed and/or deployed in the renalartery. Radiopaque materials may include barium sulfate, bismuthtrioxide, bismuth subcarbonate, powdered tungsten, powdered tantalum, orvarious formulations of certain metals, including gold, platinum, andplatinum-iridium, and these materials may be directly incorporated intothe support structure 122 or may form a partial or complete coating ofthe support structure 122.

The location, orientation and/or configuration of the slots, cuts,through holes, and/or openings formed or disposed about the supportstructure 122 define the deformation of the structure. Moreover, theslots, cuts, through holes, and/or openings can be varied along thetubular structure 122 so as to define varying regions of deformationalong the structure. In the embodiment illustrated in FIG. 6A, forexample, the tubular structure 122 includes a distal deflection region122 a, an intermediate orientation region 122 b proximal to the distaldeflection region 122 a, and a transition or flexible region 122 cproximal to the orientation region 122 b. As will be described ingreater detail below, the deflection region 122 a is configured to havea substantially helical geometry upon deployment. The orientation region122 b is configured to locate or bias the deflection region 122 a awayfrom a longitudinal axis B of the elongated shaft 116 and toward a wallof the renal artery. The transition region 122 c is configured toprovide flexibility to the treatment device 112 as the elongated shaft112 is advanced through the sometimes tortuous intravascular path fromthe percutaneous access site to the targeted treatment site within therespective renal artery (as described above with reference to FIG. 2).Further details regarding various mechanical and functional aspects ofthe different regions of the treatment device 112 are described below.

FIG. 6B is a plan view of a slot pattern configured in accordance withone embodiment of the technology. Referring to FIGS. 6A and 6B together,for example, the deflection region 122 a may be defined by a pluralityof substantially equal length transverse slots 128 arranged along thesupport structure 122 in a spiral fashion. The orientation region 122 bmay be defined by a plurality of axially spaced transverse slots 130 inwhich at least two slots differ in length. Further, as best seen in FIG.6A, the orientation region 122 b can have a smaller axial length thanthe deflection region 122 a. The transition region 122 c is locatedproximally of the orientation region 122 b and has an axial lengthgreater than each of the deflection region 122 a and the orientationregion 122 b. In the illustrated embodiment, the transition region 122 ccan include a continuous spiral cut or slit 132 having a varying pitchalong the support structure 122. In one embodiment, for example, thepitch of the spiral cut 132 can increase proximally along the elongatedshaft 116. Further details regarding various mechanical and functionalaspects of the regions of the treatment device 112 are described below.

FIG. 6C is a perspective view of the treatment device 112 including thesupport structure 122 in a delivery state (e.g., low-profile orcollapsed configuration) outside of a patient in accordance with anembodiment of the present technology, and FIG. 6D is a perspective viewof the support structure 122 in a deployed state (e.g., expandedconfiguration). For ease of understanding, the support structure 122 inFIGS. 6C and 6D is shown without energy delivery elements disposed aboutthe support structure 122.

Referring to FIGS. 6C and 6D together, the support structure 122comprises a tubular member having a central lumen to define alongitudinal axis B-B. As described above, the support structure 122includes a proximal generally flexible transition region 122 c, anintermediate orientation region 122 b, and a distal deflection region122 a. The support structure 122 is selectively transformable betweenthe delivery state (FIG. 6C) and the deployed state (FIG. 6D) byapplication of a force having at least a proximally directed axialcomponent and preferably applied at or near the distal end 126 a totransform distal deflection region 122 a and intermediate orientationregion 122 b. In one embodiment, for example, an axial force applied ator near the distal end 126 a directed at least partially in the proximaldirection deflects the distal deflection region 122 a of the supportstructure 122 such that it forms the helically-shaped support structuresuch as is shown in FIG. 6D (e.g., within the renal artery) to bring oneor more energy delivery elements (not shown) into contact with the innerwall of the renal artery.

The Deflection Region

As mentioned above, to provide the support structure 122 with thedesired deflection and deployment configuration, the deflection region122 a includes a plurality of slots 128 a, 128 b, 128 c, . . . 128 n.Again, the plurality of slots 128 a-128 n are selectively formed,spaced, and/or oriented about the longitudinal axis B-B such that thedistal deflection region 122 a deflects in a predictable manner to forma helical geometry in the deployed state within the renal artery.Outside of the renal artery or other lumen that may radially constraindeflection of the distal region 122 a, the distal region 122 a maydefine a non-helical geometry in its fully expanded configuration, suchas, for example, a substantially circular geometry as shown in FIG. 6E.As shown therein, the control wire 168 is disposed in the central lumenof the support structure 122, and is anchored at or near the distal end126 a. When the control wire 168 is placed under tension in the proximaldirection, at least a portion of the deflection region 122 a (in theabsence of any restriction in the radial direction) deflects from thesubstantially straight shape of FIG. 6C to form the substantial circularshape of FIG. 6E. More specifically, referring to FIGS. 6C-6E together,a portion of the deflection region 122 a deflects such that thedeflection slots 128 a-n deform and close or approximately close (asshown schematically in FIG. 6E) and provide contact between the edges ofthe support structure 122 framing a central region in each slot 128.Further details regarding the configuration of the slots are describedbelow.

The deflection region 122 a is arranged to deflect about a center ofcurvature Z to define a first radius of curvature r with respect to afirst surface 122 d of the support member 122, and a second radius ofcurvature R with respect to a second surface 122 e. The second radius ofcurvature R is greater than the first radius of curvature r with thedifference being the width or diameter d of the support member 122measured at its outer surface. Under a radial constraint of, forexample, the inner wall of a renal artery, the deflection region 122 adeforms to define a substantially helical deployed shape (as depicted inFIG. 6D) instead of the substantial circular shape defined in theabsence of radial constraint (as depicted in FIG. 6E). Thus, theproportions of the substantially helical deployed shape (e.g., thediameter and pitch of the helix) can vary according to the innerdiameter of the lumen (e.g., the renal artery lumen) within which thedeflection region 122 a is deformed.

The arrangement and configuration of the slots 128 a-128 n (FIG. 6C)further define the geometry of the deflectable distal region 122 a. FIG.6F, for example, schematically illustrates a slot pattern for slots 128in accordance with one embodiment of the technology to illustrate theslot spacing and orientation about the deflection region 122 a of thesupport member 122. Although only four slots 128 a-d are shown in FIG.6F, it will be appreciated that the deflection region 122 a can have anynumber of desired slots 128. Referring to FIGS. 6E and 6F together, thecenters of the slots 128 are disposed and spaced along a progressiveaxis C-C. The progressive axis C-C defines a progressive angle θ withthe longitudinal axis B-B of the support structure 122 (FIG. 6A) todefine an angular spacing of y about the center of curvature Z (FIG. 6E)in the unconstrained deployed state. The centers of the slots 128 a-128d are shown as substantially equidistantly spaced at a distance x.Alternatively, however, the center spacing between the slots may vary(x1, x2, etc.) along the progressive axis C-C. Each slot 128 furtherdefines a maximum arc length L about the longitudinal axis B-B and amaximum slot width W in the direction of the longitudinal axis B-B.

The total number of slots 128 in the region 122 a under deflectionmultiplied by the slot width W populated in a specific length definesthe first radius of curvature r in the deflected portion of thedeflection region 122 a (when placed in an unconstrained deployedstate). In one particular embodiment, for example, each slot ma have awidth W ranging from about 0.0005 to 0.010 inch (0.01 to 0.25 mm) and aslot arc length L of about 0.0005 to 0.010 inch (0.01 to 0.25 mm) so asto define a first radius of curvature r in an unconstrained deflectedstate that ranges between about 3.5 to 6 mm (7 to 12 mm diameter).Minimizing the first radius of curvature r at a maximum application ofaxial force through the deflection region 122 a of the support member122 defines the flexibility of the deflection region 122 a. Accordingly,the smaller the first radius of curvature r, the greater theflexibility; the greater the first radius of curvature r, the greaterthe stiffness. Thus, the flexibility and/or stiffness of the deflectionregion 122 a of the support member 122 can be defined by selecting thenumber and/or width of slots of the distal region 122 a. In oneembodiment, for example, the deflection region 122 a can includeapproximately 2 to 100 slots, with each having a slot width W rangingfrom about 0.0005 to 0.010 inch (0.01 to 0.25 mm) and a slot arc lengthL of about 0.0005 to 0.010 inch (0.01 to 0.25 mm) so as to define afirst radius of curvature r in an unconstrained deflected state thatranges between about 3.5 to 6 mm (7 to 12 mm diameter).

Because the first radius of curvature r of the deflection region 122 ais directly related to the number of slots 128, the number of slots 128can be few in number so as to provide for a non-continuous radius ofcurvature in a segment of the deflection region 122 a such that thesegment is substantially polygonal. FIG. 6G, for example, is a schematicplan view of a treatment device 112′ configured in accordance withanother embodiment of the technology. A deflection region 122′a of thetreatment device 112′ may include a low or reduced number of deflectionslots 128 (e.g., three slots 128 a-c are shown) such that the deflectionregion 122′a defines a substantially polygonal geometry when under atension load at its distal end (i.e., from control wire 168). In otherembodiments, a different number of slots 128 may be used to selectivelyform a desired geometry for the treatment device 112′.

Referring back to FIGS. 6B and 6C and as noted previously, thedeflection region 122 a is defined by a plurality of deflection slots128 in which each slot 128 extends substantially transverse to thelongitudinal axis B-B of the support structure 122 with the slots 128being of substantially similar arc length. Moreover, with reference toFIG. 6F, the centers of the slots 128 of the deflection region 122 a aregenerally spaced apart along a progressive axis CC that is skewed fromthe longitudinal axis BB such that the slots 128 of the deflectionregion 122 a progress in a generally spiral fashion along the supportstructure 122 in the axial direction (as best seen in FIG. 6C). Theplurality of slots 128 of the deflection region 122 a are selectivelyformed, spaced, and/or oriented about the longitudinal axis B-B suchthat the deflection region 122 a deflects or deforms in a predictablemanner so as to preferably form a helical geometry when in a deployedstate (e.g., within the renal artery).

Referring again to FIG. 6B, for example, the deflection region 122 aincludes a pattern of deflection slots 128 arranged in accordance withone embodiment of the technology to illustrate the slot spacing andorientation about the support member 122 (FIG. 6A). The centers of thedeflection slots 128 are disposed and spaced along progressive axis C-C.The progressive axis C-C defines a progressive angle θ₁ with thelongitudinal axis B-B of the support structure 122 (FIG. 6A). Theprogressive angle θ₁ defines and, more particularly, directlycorresponds to a pitch angle of the helical geometry defined by thesupport structure 122 when in a deployed state. The progressive angle θ₁can range from, for example, about zero degrees (0°) to about sixdegrees (6°), e.g., one-half degree, (0.5°), two degrees (2°), etc. Thecenters of the deflection slots 128 are shown as substantiallyequidistantly spaced apart. In other embodiments, however, the centerspacing between slots 128 may vary along the progressive axis C-C. Thetotal number of slots 128 defining the deflection region 122 a can befrom about 2 to 100 slots (e.g., about 80 slots). In one particularembodiment, the total axial length of the deflection region 122 a isabout one inch (2.54 cm). In other embodiments, however, the deflectionregion 122 a can have a different number of slots 128 and/or the slotscan have different dimensions or arrangements relative to each other.

In one embodiment, each of the deflection slots 128 comprises asubstantially rectangular central region 129 a that extends generallyperpendicular to and about the central longitudinal axis B-B of theshaft 116. The elongate lateral walls of the central region 129 a definea slot width W therebetween (e.g., about 0.0015 inch (0.038 mm)) todefine a maximum gap that may be closed when the slot 128 deforms duringdeflection of region 122 a. Each slot 128 further comprises lateralregions 129 b in communication or contiguous with the central region 129a. In one embodiment, the lateral regions 129 b are substantiallycircular and have a diameter (e.g., 0.0060 inch (0.15 mm)) to defineregions for stress relief at the ends of slots 128. The spacing betweenthe centers of the substantially circular lateral regions 129 b definean arc length L (e.g., about 0.040 inch (1.02 mm)) about thelongitudinal axis of the structure 122. In some embodiments, theselateral regions 129 b may be formed as elliptical cuts on anon-perpendicular angle relative to the longitudinal axis B-B of thesupport structure 122, 122′, 122″.

Alternate configurations of the deflection slots are possible. Forexample, the deflection slots can be more specifically formed to providea desired flexibility and deflection in the deflection region 122 a ofthe support member 122. FIGS. 6H and 61, for example, illustrate adeflection region 122 a″ having deflection slots 128′ configured inaccordance with another embodiment of the technology. In thisembodiment, the deflection slots 128′ extend substantially transverse tothe progressive axis C-C and are substantially symmetrical about theprogressive axis C-C. The slots 128′, for example, can be generally“I-shaped” and include a central region 129 a extending perpendicular tothe progressive axis C-C with two enlarged lateral regions 129 bdisposed about the central slot region 129 a. Further, the walls of thesupport structure 122″ forming the perimeter of each of the lateralregions 129 b define a substantially rectangular geometry preferablyextending substantially parallel to the longitudinal axis B-B of thesupport structure 122″ with the corners of the rectangular-shapedopenings being radiused. The central region 129 a of the slots 128′ caninclude a substantially circular cut-out region 129 c formed incommunication with the lateral regions 129 b. Alternatively, in someembodiments the central region 129 c of the slots 128′ may be generallyrectangular and not include a circular cut-out.

As best seen in FIG. 6I, the distal slots 128′ extend about thelongitudinal axis B-B of the support structure 122″ at an arc length L′of, for example, less than about 0.05 inch (1.27 mm), e.g., about 0.04inch (1.02 mm). The lateral regions 129 b define the maximum width W′ ofthe deflection slot 128′ to be, for example, about 0.03 inch (0.76 mm).The circular portion 129 c of central region 129 a is contiguous with orin communication with the lateral regions and includes a centralcircular cut-out 129 c having a diameter of e.g., about 0.01 inch (0.25mm). The central region 129 a defines a minimum width of, e.g., about0.02 inch (0.51 mm) in the longitudinal direction of the supportstructure. In one particular embodiment, the total number of slots 128′in the distal region is less than 30 slots (e.g., 25 slots), the slotspacing is about 0.03-0.04 inch (0.76-1.02 mm), and the slots areequally spaced apart in the distal deflection region 122″. In otherembodiments, however, the distal region may have a different number ofslots and/or the slots may have a different arrangement (e.g., differentdimensions, different or non-equal spacing between slots, etc.).

Alternate slot, cut, and/or opening configurations can provide desiredflexibility, stress-relief or other performance characteristics. FIG.6J, for example, is an alternative slot arrangement 128″ that can beused, for example, in either the deflection region 122 a or theorientation region 122 b (described in greater detail below) of thesupport structure 122. The illustrative slot 128″ includes a centralregion 129′a that extends substantially perpendicular and about thelongitudinal axis B-B of the support structure 122. The opposed lateralwalls of the central region 129′a are generally arcuate, each defining aradius of curvature (e.g., about 0.06 inch (1.52 mm)) with a maximum gapWWW therebetween (e.g., about 0.005 inch (0.13 mm)) to define themaximum slot gap that may be partially or fully closed during deflectionof the support structure 122. Further, disposed about the longitudinalaxis B-B of the support structure 122 are lateral regions 129′b incommunication or contiguous with the central region 129′a. The lateralregions 129′b are substantially circular and each have a diameter (e.g.,0.005 inch (0.13 mm)) to define regions for stress relief. The spacingbetween the centers of the curved lateral regions 129′b define a lengthLLL (e.g., about 0.04 inch (1.02 mm)) about the longitudinal axis B-B ofthe support structure 122. These lateral regions 129′b may be formed,for example as elliptical cuts on a non-perpendicular angle relative toa longitudinal axis of the shaft.

The configuration of a slot in the deflection region 122 a and/ororientation region 122 b of the elongated shaft can impact theflexibility of the support structure 122. For example, as shown in FIGS.6K and 6L, the inclusion (or absence) of the circular cut-out 129 c inthe central region 129 a of a slot 128, 128′, 128″ can vary the numberof contact points between the sidewalls of the slots disposed about thebisecting axis of the slot. FIG. 6K, for example, illustrates a portionof the distal region 122 a″ in a deflected or bent configuration. Thecentral circular cut-out 129 c provides for two contact points 602between the sidewalls of central region 129 a—one point of contactbetween each of the lateral regions 129 b and the central circularcut-out 129 c. In contrast and with reference to FIG. 6L, the absence ofa central circular cut-out 129 c provides for a single contact point 602between the walls of the central region 129 c when along a deflectedportion of the distal region 122″.

It should also be noted that, in order to facilitate fabrication of thesupport members 122, 122′, 122″, the deflection slots 128, 128′, 128″described above may be formed perpendicular or generally perpendicularto either the longitudinal axis B-B or the progressive axis C-C withoutimpairing the ability of the support member 122, 122′, 122″ to form thedesired helical geometry when in a deployed state.

Further, as described above with reference to FIG. 6E, when supportstructure 122 is transformed from the delivery state to the deployedstate, slots 128, 128″, 128′″ are deformed such that the walls definingcentral regions 129 a, 129″a (as shown, for example, in FIGS. 6B, 6I,and 6J) approach each other to narrow the corresponding gap widths W,WW, WWW up to and including fully closing the gap wherein one or morepairs of opposing contact points touch each other (as shownschematically in FIG. 6E and described above with reference to FIGS. 6Kand 6L).

The Orientation Region

Referring back again to FIGS. 6A-6D and as discussed previously,disposed proximally of the deflection region 122 a is the orientationregion 122 b defined by a plurality of orientation slots 130. It may bedesirable to control the orientation of the helical axis relative to thelongitudinal axis B-B of the support structure 122. For example, in atherapeutic assembly incorporating the support structure 122, it may bedesirable to direct the therapeutic assembly in a selected directionaway from the longitudinal axis B-B such that at least a portion of thedeflection region 122 a is laterally off-set from the proximal end 126 bof the support structure 122 and/or a distal end of the elongated shaft116. As best seen in FIG. 6D, for example, the orientation region 122 bcan include orientation slots or openings 130 that are formed, spacedand/or oriented to provide for an orientation axis B-B that is skewed(e.g., from about 45 degrees (45°) to about 90 degrees (90°)) relativeto the longitudinal axis B-B and orients the helically shaped geometryof the deflection region 122 a adjacent the renal artery wall with thehelical axis directed axially along the renal artery.

The orientation slots 130 can have a variety of differentarrangements/configurations. Referring to FIG. 6B (and with reference toFIG. 6M), for example, the centers of orientation slots 130 are disposedand spaced along an orientation axis D-D that is radially offset fromthe progressive axis C-C (e.g., by about 90° about the longitudinal axisB-B of the support structure 122). The orientation axis D-D may extendgenerally parallel to the longitudinal axis B-B or, alternatively, maybe skewed at a selected angle relative to the longitudinal axis B-B (asdescribed in greater detail below with reference to FIG. 6N). In theillustrated embodiment, the centers of the orientation slots 130 areshown as substantially equidistantly spaced apart. In other embodiments,however, the spacing between the individual slots 130 may vary along theorientation axis D-D. Each slot 130 defines a maximum arc length LLabout the longitudinal axis B-B and a maximum slot width WW in thedirection of the longitudinal axis B-B.

Referring to FIG. 6B, in one embodiment the orientation slots 130 caninclude groups of slots of varying arc length LL about the longitudinalaxis B-B. For example, the orientation slots 130 can include a firstgroup of orientation slots 130 a having a first arc length, a secondgroup of orientation slots 130 b having a second arc length less thanthe first arc length of the first group of orientation slots 130 a, anda third group of orientation slots 130 c having a third arc length lessthan the second arc length of group 130 b. For example, in oneparticular embodiment, the first group of orientation slots 130 a has anarc length of about 0.038 inch (0.97 mm), the second group oforientation slots 130 b has an arc length of about 0.034 inch (0.86 mm),and the third group of orientation slots 130 c has an arc length ofabout 0.03 inch (0.76 mm). In other embodiments, however, theorientation slots 130 may have different sizes and/or arrangementsrelative to each other. For example, in some embodiments one or moregroups of orientation slots 130 may have different slot widths (inaddition to, or in lieu of, varying arc lengths).

In one embodiment, the total number of slots 130 defining theorientation region 122 b is less than 20 slots (e.g., about 5 to 15slots, about 6 to 12 slots, etc.) equally spaced over the orientationregion 122 b. Further, in one particular embodiment, the total axiallength of the orientation region 122 b is about 0.2 to 0.25 inch (5.08to 6.35 mm). In other embodiments, the orientation region 122 b may havea different number of slots and/or a different arrangement and/ordimensions.

Alternate configurations of the orientation slots are possible. Forexample, Referring back again to the pattern illustrated in FIG. 6I,orientation slots 130′ may be substantially elongated defining apreferably maximum arc length LL′ about the longitudinal axis B-B and amaximum slot width WW in the direction of the longitudinal axis B-B. Inone particular embodiment, for example, each orientation slot 130′ has awidth W′ ranging from about 0.0005 to 0.010 inch (0.01 mm to 0.03 mm)and a slot arc length LL′ of about 0.0005 to 0.010 inch (0.01 mm to 0.03mm) so as to define a first radius of curvature r in an unconstraineddeflected state that ranges between about 7 to 12 mm. In otherembodiments, however, the orientation slots 130′ may have otherdimensions and/or arrangements.

In the illustrated embodiment, the orientation slots 130′ extendgenerally perpendicular to the orientation axis D-D and aresubstantially symmetrical about the orientation axis D-D. Theorientation slots 130′ are generally “I-shaped” having a central region131 a extending perpendicular to the orientation axis D-D with twoenlarged lateral regions 131 b disposed about the central slot region131 a for stress relief. In this embodiment, the walls of the supportstructure 122″ forming the perimeter of each of the lateral regions 131b can define, for example, a substantially rectangular geometryextending substantially parallel to the longitudinal axis B-B of thesupport structure 122″ with the corners of the rectangular-shapedopenings being radiused (not shown). Further, central regions 131 a ofthe individual orientation slots 130′ may be generally rectangular, ormay have another suitable shape.

Each of the orientation slots 130′ depicted in FIG. 6I can include asubstantial rectangular central region 131 a that extends substantiallyperpendicular and about the longitudinal axis B-B of the supportstructure 122. The elongate lateral walls of the central region 131 adefine a gap therebetween (e.g., about 0.0015 inch (0.038 mm)) to definethe maximum closing gap of the slot during deflection of the structure122. Each slot 130′ can also include lateral regions 131 b disposedabout the longitudinal axis B-B and in communication or contiguous withthe central region 131 a. The lateral regions 131 b define asubstantially rectangular geometry preferably extending substantiallyparallel to the longitudinal axis B-B of the support structure 122″ withthe corners of the rectangular-shaped openings being radiused to defineregions for stress relief. The spacing between the centers of thesubstantially rectangular lateral regions 131 b define an arc length L(e.g., about 0.04 inch (1.02 mm)) about the longitudinal axis B-B of thesupport structure 122″. Alternatively, lateral regions 131 b may beformed as elliptical cuts on a non-perpendicular angle relative to thelongitudinal axis B-B of the support structure 122, 122′, 122″.

In some embodiments, the total number of slots 130′ in the orientationregion is generally less than ten slots, e.g., five slots, the slotspacing can be, e.g., about 0.03 to 0.04 inch (0.76 mm to 1.02 mm), andthe slots 130′ can be equally spaced apart. Further, in some embodimentsthe orientation axis D-D can be generally parallel to the longitudinalaxis B-B and radially offset from the progressive axis C-C at a minimumarc length distance of, e.g., about 0.01 inch (0.25 mm) over an angleranging from about 50° to less than 90° about the longitudinal axis B-Bof the support structure 122″.

In yet another embodiment, the orientation slots 130 may be disposedalong an orientation axis that is substantially skewed with respect tothe longitudinal axis B-B. FIG. 6N, for example, is a plan view of aslot pattern configured in accordance with another embodiment of thetechnology. In this embodiment, the orientation slots 130 are disposedon an orientation axis D₂-D₂ that may be skewed relative to thelongitudinal axis B-B by an angle θ₂ ranging from, e.g., about 0 degrees(0°) to about 45 degrees (45°). The angled orientation axis D₂-D₂provides for an orientation region 122 b having a tapered helicalgeometry upon deployment of the support structure 122. FIG. 6O, forexample, is a schematic illustration of a portion of a treatment devicehaving a support structure including the slot pattern of FIG. 6N in adeployed state within a renal artery of a patient.

The Flexible/Transition Region

Referring again to FIG. 6A, disposed proximally of the orientationregion 122 b is the flexible or transition region 122 c. As noted above,the flexible region 122 c can include, for example, the transitionalhelical or spiral slit or cut 132 having a variable pitch over itslength. The variable pitch of the spiral cut 132 along the length of theflexible region 122 c provides the support structure 122 with variableflexibility along the length of the elongated shaft 116. In oneembodiment, for example, the transitional cut 132 extends over an axiallength of, e.g., about 170 mm initiating proximal to the orientationregion 122 b. In other embodiments, however, the transitional cut 132may have a different length.

As illustrated in FIGS. 6C and 6D, in some embodiments the pitch of thetransition cut 132 may vary over the length of the transition cut todefine multiple, different transition regions (four transition regions132 a, 132 b, 132 c, and 132 d are shown in FIG. 6C). More specifically,in one embodiment, the cut 132 defines a first transitional portion 132a having a first pitch by forming, e.g., five revolutions about thetubular support structure 122 at a spacing of 0.02 inch (0.51 mm) andtransitions to a second transitional portion 132 b having a second pitchdefined by, e.g., five revolutions at a spacing of 0.040 inch (1.02 mm).The cut 132 continues to define a third transitional portion 132 ahaving a third pitch defined by, e.g., ten revolutions at a spacing of0.06 inch (1.52 mm) and transitions to a fourth pitch defined by, e.g.,twenty revolutions at a spacing of 0.08 inch (2.03 mm). It should beappreciated in the above example that, considering each sequentialtransitional portion 132 in order from the distal end to the proximalend of transition region 122 c, the slit pitch spacing increases and theflexibility of tubular support structure 122 decreases.

The transitional cut 132 may have a generally constant width of, e.g.,about 0.0005 inch (0.01 mm) over its length, or the width of thetransitional cut 132 may vary over its length. The transitional cut 132can also include at each end a substantially circular void contiguouswith or in communication with the transitional cut. In otherembodiments, however, the transitional cut 132 can have a differentarrangement and/or different dimensions. For example, rather than havingstepwise increases in pitch, the transitional cut 132 may have acontinuously increasing pitch from the distal end to the proximal end oftransition region 122 c.

Alternate slot, cut and/or opening configurations can provide for thedesired flexibility, stress-relief or other performance characteristicsin the flexible region 122 c in lieu of the transition cut 132. In someembodiments, for example, opening or apertures may be selectively formedin the elongated shaft 116 to provide the desired flexibility. Theindividual openings or apertures of the flexible region 122 c can, forexample, have centers disposed along an axis that extends parallel tothe central longitudinal axis B-B of the support structure 122. FIGS. 7Aand 7B, for example, illustrate the support structure 122 with analternate arrangement for the flexible region 122 c, having throughholes or openings 132′a, 132′b, 132′c that each extend through thetubular support structure 122. The openings 132′, for example, can bealternately disposed on axes that are angularly spaced from one anotherabout the longitudinal axis B-B of the support structure 122. In theillustrated embodiment, for example, opening 132′b is angularly disposedat 90° relative to the axially adjacent openings 132′a and 132′c. Inother embodiments, however, the openings 132′ may have a differentarrangement.

FIG. 8A is a broken perspective view in partial section of a treatmentdevice 100 including a catheter having an elongated shaft 116 with adistal region 120 having a support structure 122 for delivery anddeployment of a therapeutic or treatment assembly 121 at a targettreatment site in a lumen and, in particular, for performing renaldenervation within a renal artery. Disposed at a proximal end of theelongated shaft 116 is a handle assembly 134, shown schematically, formanipulation of the elongated shaft 116 and the therapeutic assembly121. More specifically, the handle assembly 134 is configured to providefor remote operation of a control member 168 (e.g., a control wire) forcontrolling or transforming the therapeutic assembly 121 between adelivery state and a deployed state (shown in FIG. 8A).

The system 100 is configured to deliver the therapeutic assembly 121 tothe treatment site in a delivery state (not shown) in which thetherapeutic assembly 121 is substantially linear (e.g., straight) suchthat the energy delivery elements 124 are substantially axially alignedalong the support member 122. Energy supply wires 25 may be disposedalong an outer surface of the support member 122 and coupled to each ofthe energy delivery elements 124 for supplying treatment energy to therespective energy delivery elements 124. Once located at the treatmentsite within the renal artery, actuation of the control member 168 thattransforms the therapeutic assembly 121 from the delivery state to thedeployed state as shown. In the illustrated embodiment, the control wire168 is disposed within the tubular support structure 122. One end of thecontrol member 168 may be affixed at or near the distal end 126 a of thesupport structure 122 (e.g., terminating in a tip member 174). Theopposite end of the control member 168 can terminate within the handleassembly 134 and be operably coupled to an actuator for transforming thetherapeutic assembly 121 between the delivery and the deployed state.

The tension in the control member 168 can provide a proximal and/oraxially directed force to the distal end 126 a of the support structure122. For example, under the influence of the tension force in thecontrol member 168, the distal region 122 b of the support structure 122deflects. The distal deflection region 122 a preferably include aplurality of slots 128 (only two are shown as 128′a and 128′b). Asdescribed above, the slots 128′a and 128′b are disposed along aprogressive axis. The slots 128′a and 128′b formed in the distal region122 a of the support structure bias the deflection of the distal region122 a so as to form one or more curved portions, each having a radius ofcurvature preferably defined by the number of deflection slots 128, theindividual slot width, slot configuration, and/or slot arrangement. Asthe distal region 122 a continues to deflect, it radially expandsplacing one or more of the spaced-apart energy elements 124 into contactwith the inner wall 55 of the renal artery. The support structure 122,when subject to the tension of the control wire 168 and the radialconstraints of the vessel wall 55, is configured to form a substantiallyhelical shape so as to axially space and radially offset the energydelivery elements 124 from one another. Moreover, because the deflectionregion 122 a of the support structure 122 is configured to form ahelical geometry within the renal artery when under a tension load, thetreatment assembly 121 is not expected to radially overload the wall 55of the renal artery. Rather, the support structure 122 deforms to formthe helix under a continuously increasing tension load.

As discussed above, the progressive angle of the axis (e.g., progressiveaxis C-C) along which the deflection slots 128, 128′, 128″ are disposeddefines the helical angle of the resulting deployed arrangement. In oneembodiment, an amount of tension to fully deploy the therapeuticassembly 121 is typically less than, for example, about 1.5 lbf(pound-force) (0.68 kgF) applied at the distal end 126 a of thetherapeutic assembly 121, e.g., between about 1 lbf (0.45 kgF) to about1.5 lbf (0.68 kgF). In the helically shaped deployed state of FIG. 8A,the slots 128′ are disposed along the interior surface of the helix withthe supply wires 25 for the energy delivery elements 24 disposed on anouter surface of the helix so as to form a “spine” of the assembly. Thesupply wires 25 can extend along the length of the treatment device 112to an appropriately configured energy generator (not shown).

The support structure 122 of the therapeutic assembly 121 includes aproximal portion that defines an orientation region 122 b of theassembly for locating the therapeutic assembly adjacent to the wall ofthe renal artery. As shown in FIG. 8A, the proximal region of thesupport structure 122 includes a plurality of orientation slots 130′. Inoperation, upon actuation of the handle assembly 134 to place thecontrol wire 168 under tension, the orientation region 122 b deflects ina radially outward direction within the renal artery to locate thetherapeutic assembly 121 into contact with the arterial wall 55. Morespecifically, the slots 130′ deform under the tension force so as todeflect the orientation region 122 b radially outward from thelongitudinal axis B-B of the support structure 122. In the fullydeployed state, the resultant helical geometry of the therapeuticassembly 121 at the distal end of the support structure 122 ispreferably offset from the longitudinal axis B-B at the proximal end ofthe support structure 122 such that the helical axis H-H and thelongitudinal axis B-B of the support structure 122 are non-coaxial. Theaxes H-H, B-B may be parallel to one another or, alternatively, skewedwith respect to one another.

The proximal end of the support structure 122 can be coupled to aseparate member forming the elongated shaft 116 of the device 112.Alternatively, the support structure 122 and the elongated shaft 116 maybe a single unitary member that extends proximally from the distal end126 a into the handle assembly 134. In one embodiment, the tubularsupport structure 122 is formed from a metallic shape-memory material(e.g., nitinol). Further, in one embodiment the support structure 122can have an axial length of less than five inches (12.7 cm) and, morespecifically, about two inches (5.08 cm); an outer diameter of about0.020 inch (0.57 mm) and, more specifically, ranging between about 0.016inch (0.41 mm) to about 0.018 inch (0.46 mm); a tubular wall thicknessof less than 0.005 inch (0.13 mm) and, more particularly, about 0.003inch (0.08 mm). In several embodiments, the elongated shaft 116 can beformed from stainless steel metal tubing having an outer diameter of,e.g., about 0.020 (0.57 mm) to about 0.060 inch (1.52 mm). In couplingthe proximal support structure 122 to the elongated shaft 116, a joint119 may be provided therebetween to provide the desired transfer oftorque from the elongated shaft 116 to the support structure 122 whennavigating to the treatment site. More specifically, each end of thesupport structure 122 and the elongated shaft 116 may respectivelyinclude mating notches that permit the ends of the tubular members tointerlock with one another as shown in the joint assembly 120. In someembodiments, disposed about the joint 119 is a stainless steel sleevethat is crimped about the juncture to provide additional support to thejoint 119.

As noted above, the control member 168 can be a control rod or wire thatextends the axial length of the catheter device 112 from at or near thedistal end 126 a of the support structure 122 to the handle assembly134. The control wire 168 can be comprised of ultra high molecularweight (UHMW) fiber, such as for example high strength, gel-spun fibersold under the trademark SPECTRA or other sufficiently strongpolyethylene fiber. Alternatively, nitinol, a para-aramid syntheticfiber sold under the trademark KEVLAR, or other mono- or multi-filamenttypes can be used provided they are compatible with the application andcan transfer the tensile force to the distal end of the therapeuticassembly 121 over the length of the treatment device 112.

To provide the desired tensile force at the distal end of thetherapeutic assembly 121, the control wire 168 may be anchored at ornear the distal end 126 a of the support structure 122. FIGS. 8B-8D, forexample, illustrate various anchoring configurations for the controlwire 168. More specifically, as shown in FIG. 8B, the distal end 126 aof the support structure includes a slot adjacent the axial opening totie and anchor the control wire 168 therethrough. In an alternateanchoring arrangement shown in FIG. 8C, the control wire 168 extendsthrough the axial opening at the distal end 126 a. The control wire 168can be encased in a coil 174 material to stop the control wire 168 fromsliding proximally into the distal portion of the support structure 122.FIG. 8D illustrates another tip 174 configured in accordance with anembodiment of the disclosure. In this arrangement, the control wire 168can be tripled-knotted to provide an enlarged surface of the controlwire 168 on which to coat the polymer material that is formed into atip.

Referring back to FIG. 8A, the control wire 168 can extend through theelongated shaft 116 to the handle assembly 134. In operation of thehandle assembly 134 to tension and release the control wire 168 whentransforming the therapeutic assembly between deployed and deliveredstates, friction occurs between the moving control wire 168 and theinterior of the relatively stationary elongated shaft. One embodiment ofthe control wire 168 assembly is configured to minimize the frictioncontact between the control wire 168 and the interior of the elongatedshaft 116. For example, as shown in FIG. 8A, a sleeve 170 can bedisposed and bound to the control wire 168 to provide a relativelylow-friction outer surface. The sleeve 170 preferably has axial lengththat is less than that of the elongated shaft 116 and, more preferably,covers a substantially proximal portion of the control wire 168 withinthe elongated shaft 116. During operation of the handle assembly 134 totension and release the control wire 168, the tubular sleeve 170 isconfigured to move with the control wire 168 and acts as a bearingsurface against the interior of the elongated shaft 116, therebyreducing friction between the control wire 168 and the elongated shaft116.

In several embodiments, a control member may be configured to be outsideof the support structure of the treatment assembly that carries theenergy delivery elements. For example, the support structure of thetreatment assembly may instead be externally wound or wrapped around thecontrol member. In such arrangements, the control member engages aportion of the support structure to apply a force that converts thesupport structure and the treatment assembly between its delivery anddeployed state.

FIGS. 9A and 9B, for example, illustrate a distal portion of a treatmentdevice 212 configured in accordance with further embodiments of thepresent technology. More specifically, FIGS. 9A and 9B illustrate atreatment assembly 221 having a tubular support structure 222 helicallywrapped about a control member 268 with a plurality of energy deliveryelements 224 disposed about the support structure 222. The supportstructure 222 can include a number of features generally similar to thesupport structures 22 and 122 described above.

In the illustrated embodiment, a distal region or portion 222 a of thesupport structure 222 terminates in an end piece (e.g., a conical orbullet-shaped tip 250) or, alternatively, a collar, shaft, or cap. Thetip 250 can include a rounded distal portion to facilitate atraumaticinsertion of the treatment device 212 into a renal artery. A proximalregion or portion 222 b of the support structure 222 is coupled to andaffixed to an elongated shaft 216 of the treatment device 212. Theelongated shaft 216 defines a central passageway for passage of acontrol member 268. The control member 268 may be, for example, a solidwire made from a metal or polymer. The control member 268 extends fromthe elongated shaft 216 and is affixed to the distal region 222 a of thesupport structure 222 at the tip 250. Moreover, the control member 268slidably passes through the elongated shaft 216 to an actuator 236 in ahandle assembly 234.

In this embodiment, the control member 268 is configured to movedistally and proximally through the elongated shaft 216 so as to movethe distal region 222 a of the support structure 222 accordingly. Distaland proximal movement of the distal region 222 a respectively lengthenand shorten the axial length of the helix of the support structure 222so as to transform the treatment assembly 221 between a delivery (FIG.9B) and deployed state (FIG. 9A) such that the energy delivery elements224 move a radial distance Y to engage the walls of the renal artery(not shown).

In an alternate embodiment, the treatment assembly may not be affixed toa control member at the distal region of the tubular support structure.FIG. 9C, for example, illustrates another embodiment of a treatmentdevice 212′ and treatment assembly 221′ having a helical shaped supportstructure 222 with a plurality of energy delivery elements 224 disposedabout the helical support structure 222. A distal end region 222 a ofthe support structure 222 is coupled to a collar element 274 thatincludes a passage sized and shaped to slidably accommodate the controlmember 268 that terminates at an end piece 250. In this embodiment, thecontrol member 268 comprises control wire that extends from theelongated shaft 216 and moves distally and proximally through theelongated shaft 216 and the collar element 274. A stopper member 275 canbe connected to the control wire 268 proximal to the collar element 274.

The control wire 268 facilitates the expansion and/or contraction of thehelical support structure 222 when it is pulled or pushed to shorten orlengthen the helical support structure 222. For example, pulling (i.e.,an increase in tension) of the control wire 268 may trigger expansion ofthe helical structure 222, while pushing (i.e., an increase incompression) of the control wire 268 may lengthen the helical supportstructure 222 to a compressed configuration. In some embodiments,helical structure 222 has elastic or super-elastic properties such thatwhen force is removed the helical structure 222 elastically returns to arelaxed state. Force may be applied by the end piece 250 or the stoppermember 275 to transform the treatment assembly 221′ between the deliveryand deployed states. For example, the control wire 268 may be pusheddistally such that the stopper member 275 engages and distally moves thecollar element 274 so as to lengthen the support structure 222 andreduce its diameter placing it in a delivery state. Alternatively, thecontrol wire 268 may be pulled proximally to cause end piece 250 toengage and proximally move the collar element 274 so as to shorten thehelical support structure 222 and increase its diameter, thereby placingit in a deployed state.

When the helical support structure 222 has a pre-formed helical shapememory, the helical support structure 222 elastically expands to itspre-formed shape when the collar element 274 is not engaged with eitherthe stopper member 275 or the end piece 250. In this way the helicalsupport structure 222 may expand to contact the inner wall of the renalartery with a relatively consistent force. Furthermore, in someembodiments the force exerted in the renal arterial wall by thepre-formed helical structure 222 may be less dependent on the operator'scontrol at the handle assembly 234 (FIG. 9A).

FIGS. 9D and 9E illustrate another embodiment of a treatment device212″. In this embodiment, control member 268′ comprises a hollow tubedefining an internal passage for a guide wire 266 to facilitateinsertion of the treatment assembly 221 through an intravascular path toa renal artery. Accordingly, the treatment device 212″ is configured foran OTW or RX delivery as described herein. The control member 268′defines an internal lumen extending through the control member andcomposed of, for example, a polyimide tube with wall thickness less thanabout 0.003 inch (0.08 mm) (e.g., about 0.001 inch (0.02 mm)) and alumen with a diameter of less than about 0.015 inch (0.38 mm) (e.g.,about 0.014 inch (0.36 mm)). In addition to engaging and tracking alongthe guide wire 266, the device 212″ transforms the configuration of thetreatment assembly 221 between the delivery state and the deployed statein a manner similar to that of treatment device 212 shown and describedwith respect to FIGS. 9A and 9B.

FIGS. 10A and 10B are side views of another embodiment of a treatmentdevice 310 having an OTW configuration and including a tubular controlmember 368 defining a guide wire lumen that extends substantially theentire length of the device. The control member 368 is configured toslidably receive a guide wire 366 such that the treatment device 310 maybe tracked over the guide wire 366 using over-the-wire techniques. Thecontrol member 368 is slidably disposed within an elongated shaft 316.In one embodiment, the control member 368 is allowed to slide relativeto the elongated shaft 316 within a thin-walled sleeve (not shown) thatis attached to an inner surface of the elongated shaft 316 using thermalor adhesive bonding methods. The thin-walled sleeve may be formed out ofa polymeric material such as, but not limited to, polyimide. In otherembodiments, however, the treatment device 310 may not include thesleeve.

The treatment device 310 also includes a treatment assembly 312extending between a distal portion of the elongated shaft 316 and adistal portion of the control member 368. The treatment assembly 312 isdeployable at a target location within the vasculature and includesmultiple (e.g., six) energy delivery elements 324 (e.g., electrodes) fordelivering energy from an energy generator 326 to a vessel wall. In someembodiment, the energy delivery elements or electrodes 324 may beequally spaced apart along the length of the support structure 322. Inother embodiments, however, the number and/or arrangements of the energydelivery elements 324 may vary. The axial length of the supportstructure 322 can be between, e.g., about 17 mm to 20 mm. In otherembodiments, however, the support structure 322 may have a differentlength so long as the structure sufficiently supports the number ofelectrodes in a desired electrode spacing pattern.

The energy delivery elements 324 may be a series of separate bandelectrodes spaced along that support structure 322. Band or tubularelectrodes may be used in some embodiments, for example, because theyhave lower power requirements for ablation as compared to disc or flatelectrodes. In other embodiments, however, disc or flat electrodes arealso suitable for use. In still another embodiment, electrodes having aspiral or coil shape may be utilized. In one embodiment, the individualenergy delivery elements 324 may have a length ranging fromapproximately 1-5 mm, and the spacing between each of the energydelivery elements 324 may range from approximately 1-10 mm. In otherembodiments, however, the energy delivery elements 324 may havedifferent dimensions and/or arrangements.

The energy delivery elements 324 may be formed from any suitablemetallic material (e.g., gold, platinum, an alloy of platinum andiridium, etc.). In one embodiment, for example, energy delivery elements324 may be 99.95% pure gold with an inner diameter that ranges betweenabout 0.025 inch (0.64 mm) and 0.030 inch (0.76 mm), and an outerdiameter that ranges between about 0.030 inch (0.76 mm) and 0.035 inch(0.89 mm). Electrodes of smaller or larger dimensions, i.e., diameterand length, are also suitable for use herein.

Each energy delivery element or electrode 324 is electrically connectedto the generator 326 by a conductor or wire (not shown) extendingthrough a lumen of the elongated shaft 316. Each electrode 324 may bewelded or otherwise electrically coupled to the distal end of its energysupply wire and each wire can extend through the elongated shaft 316 forthe entire length of shaft such that a proximal end thereof is coupledto the generator 326.

The support structure 322 may comprise a shape memory component thatextends at least the length of the assembly 312. Shape memory supportstructure 322 is utilized to deploy or transform the treatment assembly312 from a delivery state shown in FIG. 10A (i.e., a substantiallystraightened form) to a deployed state shown in FIG. 10B (i.e., a presetspiral or helical form). More particularly, the shape memory componentof support structure 322 may be constructed from a shape memory materialthat is pre-formed or pre-shaped into the deployed state. Certain shapememory materials have the ability to return to a predefined orpredetermined shape when subjected to certain thermal conditions. Whenshape memory materials, such as nickel-titanium (nitinol) or shapememory polymers or electro-active polymers, are at a relatively lowtemperature, items formed therefrom may generally be deformed quiteeasily into a new shape that they retain until exposed to a relativelyhigher transformation temperature, which in embodiments hereof is abovea normal body temperature of 37° C., that then returns the items to thepredefined or predetermined shape they held prior to the deformation. Insome embodiments, support structure 322 may be formed from such a shapememory material, inserted into the body in a deformed, low profilestraightened state, and returned to a “remembered” preset shape onceshape memory support structure 322 is exposed to a transformationtemperature in vivo. Thus, shape memory support structure 322 has atleast two stages of size or shape, a generally straightened orstretched-out coil configuration of a sufficiently low profile fordelivery to the treatment site as shown in FIG. 10A and a spiral orhelical configuration that places energy delivery elements 324 intocontact with a vessel wall 55, which is shown as a dashed line in FIG.10B. The delivery state may also be achieved by mechanicallystraightening shape memory support structure 322 by the operator or viaa tensioning device. Referring to FIG. 10A, in one embodiment a deliverydiameter D1 of shape memory support structure 322 may be between about 1and 2 mm to accommodate delivery to a target vessel, such as a renalartery.

The treatment assembly 312 may also include an insulating component (notshown) that functions to electrically isolate shape memory supportstructure 322 from the energy delivery element 324. The insulatingcomponent, for example, can include a tubular sheath defining a lumenthat is formed from an electrically insulative material, such aspolyethylene block amide copolymer. In an embodiment, the insulatingcomponent may have an outer diameter of approximately 0.027 inch (0.69mm) and an inner diameter of approximately 0.023 inch (0.59 mm). Theinsulating component is configured to house shape memory supportstructure 322 as well as housing wires to provide additional protectionthereto, and electrodes 324 are attached to or disposed aroundinsulating component. A distal end of the insulating component may beattached to a distal end of guide wire shaft 368 by any suitable methodsuch as an adhesive, a sleeve, or other mechanical method. In oneembodiment depicted in FIG. 10A, the distal end of the insulatingcomponent is preferably attached to the distal end of guide wire shaft368 via a cyanoacrylate adhesive and a polymer sleeve surrounds andholds together the distal ends to form a tapered distal tip 350 of thetreatment assembly 312. In other embodiments, however, the insulatingcomponent may have a different arrangement relative to the treatmentassembly 312.

Both shape memory support structure 322 and the insulating componentpreferably extend along the length treatment assembly 312 and proximallyextend into the distal end of the shaft 316, e.g., at least one or twocentimeters, such that the proximal end of shape memory supportstructure 322 is sufficiently removed from the energy delivery elements324 to avoid any thermal effects therefrom.

As the shape memory support structure 322 of the treatment assembly 312assumes the deployed configuration, the distal end of the insulatingcomponent proximally retracts such that the treatment assembly 312radially expands into contact with vessel wall, since the distal end ofthe insulating component is coupled to distal end of inner tubular shaft368. The control member 368 also slightly proximally retracts withinelongated shaft 316 in order to allow deployment of the treatmentassembly 312.

In each of the previously described embodiments of the treatment ortherapeutic devices, the control member is configured as a wire, tubularshaft or other inner member that applies a force at or near the distalend of the support structure to alter the configuration of thetherapeutic assembly between a delivery state and a deployed state. Inother embodiments, however, an actuating force may be applied at or nearthe proximal end of the therapeutic assembly to transform theconfiguration of the assembly.

FIGS. 11A and 11B, for example, illustrate an embodiment of a treatmentdevice 612 configured to apply a deforming force to a proximal end ofthe treatment assembly. The treatment device 612 includes a tubularelongated shaft 616 having a proximal end coupled to a handle assembly634 and a distal end coupled to a treatment assembly 621. Theillustrated treatment assembly 621 includes a tubular support structure622 carrying a plurality of energy delivery elements 624. Energy supplywires (omitted for clarity) extend internally or externally along thesupport structure 622 to provide a treatment energy to the energydelivery elements 624. A proximal end 622 b of the support structure 622is disposed within and affixed to the distal end of the tubularelongated shaft 616. The support structure 622 defines a preferablyhelical shape wrapped about a tubular control member 668 having aninternal lumen for passage of a guide wire 666 that can extend distallybeyond the treatment assembly 621 and proximally beyond the handleassembly 634. Accordingly, the treatment device 612 is configured for anover-the-wire delivery. The support structure distal end 622 a iscoupled to a distal region of the tubular control member 668. Thecontrol member 668 extends proximally into the elongated shaft 616 andis affixed to an internal surface of the handle assembly 634.Accordingly, the distal end 622 a of the support structure 622 canremain at a fixed distance from the handle assembly 634.

The elongated shaft 616 extends proximally into the handle assembly 634,and is coupled to an actuator 636. In one embodiment, the actuator 636provides for linear displacement or direct longitudinal translation ofthe elongated shaft 616. The actuator 636 is shown schematically as aslider-in-groove assembly. In operation, proximal translation of theactuator 636 translates the axial shaft 616 proximally with respect tohandle assembly 634 and thus to inner member 668. The distal end of theelongated shaft 616 applies a tension force to the affixed proximal end622 b of the support structure 622. Because the distal end 622 a of thesupport structure 622 is affixed to the control member 668, proximaltranslation of the proximal end 622 a of the support structure 622elongates the structure so as to place the treatment assembly 612 in alow profile delivery state (FIG. 11A). Distal translation of theactuator 636 results in compressing the support structure 622 axially soas to place the treatment assembly 612 into a deployed state (as bestseen in FIG. 11B).

Alternate configurations of the handle assembly 634 can provide thedesired axial translation of the elongated shaft 616. FIG. 11C, forexample, illustrates an alternate arrangement of the handle assembly 634that provides for a pivot-type actuator 636′ to axially translate theelongated shaft 616. The actuator 636′ can include a pivot connection tothe elongated shaft 616. Accordingly, angular rotation of actuator 636′about the pivot connection linearly translates the elongated shaft 616.The amount of angular rotation of the actuator 636′ can be controlled bythe distance between elongated shaft 616 and the pivot point. FIG. 11Dillustrates another alternate configuration of the handle assembly 634including a gear-type actuator 636″ to linearly translate the elongatedshaft 616. In one embodiment, for example, the actuator 636″ includes aknob or thumb roller connected to a small gear. The elongated shaft 616may be connected to a larger gear engaged with the a small gear suchthat the small gear rotates, which in turn rotates the larger gear andtranslates the elongated shaft 616. The difference in gear sizes allowsa small roller rotation to create a large translation of the elongatedshaft 616.

In the previously described embodiments of the treatment device, thetreatment assembly of the devices was altered between a delivery stateand a deployed state by pushing or pulling on either a proximal end or adistal end of the support structure depending upon the configuration. Itshould be understood that the treatment device may be configured forselectively applying a force at or near either the proximal or thedistal end of the support structure such that a clinician may select theend for relevant movement depending, for example, the constraints aroundthe supporting structure.

In several alternate configurations, the treatment assembly can bemovable between the delivery and deployed states by either inserting orretracting a control member (e.g., an insertion member, stylet,pre-shaped member, etc.) into a distal treatment section or portion of atubular support structure. FIGS. 12A and 12B, for example, are sideperspective views of a portion of a treatment device 700 configured inaccordance with an additional embodiment of the technology. Morespecifically, FIG. 12A illustrates the treatment device 700 in adelivery state (e.g., low-profile or collapsed configuration) outside apatient, and FIG. 12B illustrates the treatment device 700 in a deployedstate (e.g., expanded configuration). Referring to FIGS. 12A and 12Btogether, the treatment device 700 includes an elongated shaft 701having a distal portion 702, and a treatment section 704 at the distalportion 702. The treatment device 700 also includes a plurality ofenergy delivery elements 706 carried by the treatment section 704. Thetreatment device 700 further includes a control member 708 (shownschematically in broken lines) coupled to the treatment device 700 andslidably moveable relative to the treatment section 704. As will bedescribed in greater detail below, the treatment section 704 or thecontrol member 708 comprises a pre-formed helical shape, and the otherof the treatment section 704 and the control member 708 comprises asubstantially straight shape. The treatment section 704 and the controlmember 708 are movable relative to one another to alter the treatmentdevice 700 between a low-profile delivery state (FIG. 12A) and anexpanded delivery state having the pre-formed helical shape (FIG. 12B).For purposes of illustration, control member 708 is shown in both FIGS.12A and 12B. As described in greater detail below, in variousembodiments, the control member 708 may be either inserted into orwithdrawn from the treatment section 704 to alter the treatment device700 between the delivery and deployed states.

For example, in one embodiment described below, the control member 708can include a stylet, stiffening mandrel, straightening member, or aprocedural guide wire extending along at least a portion of the lengthof the treatment device 700 and configured to straighten a pre-shapedhelical treatment section 704 of the treatment device 700 duringdelivery. More specifically, the control member 708 facilitates theexpansion and/or contraction of the treatment section 704 when thecontrol member 708 is pulled or pushed, respectively, relative to thetreatment section 704. In another embodiment, a pre-shaped controlmember (e.g., stylet or pre-shaped member) can provide a helical shapeto a relatively flexible, distal portion 702 of the treatment device700.

FIGS. 13A-15B are directed to various embodiments of treatment devicesincluding features generally similar to the treatment device 700described above with reference to FIGS. 12A and 12B. FIGS. 13A and 13B,for example, are cross-sectional views of a treatment device 712including a treatment section or assembly 721 having a plurality ofenergy delivery elements 724 carried by a relatively flexible tubularsupport structure 722 defining a central lumen 729. The tubular supportstructure 722 includes a distal end 722 a having an axial opening forpassage of a guide wire 766 (FIG. 13A) extending through the lumen 729.The tubular support structure 722 has a proximal end 722 b coupled to oraffixed to the distal end of a tubular elongated shaft 716. Theelongated shaft 716 defines a central lumen for housing the guide wire766. Accordingly, the present configuration provides for anover-the-wire delivery from an access site in which the guide wire 766is initially inserted to a treatment site (e.g., within a renal artery),and the treatment device 712 is installed over the guide wire 766.Inserting the substantially straight and linear guide wire 766 throughthe flexible tubular support structure 722 maintains the tubular supportstructure 722 in a normally straight shape so as to place the treatmentassembly 721 into a low profile delivery state for delivery to thetreatment site in the renal artery. The guide wire 766 may be of aconstant stiffness along its length or may have a variable stiffness orflexibility along its length so as to provide increased flexibility, forexample, in the proximal to distal direction.

Once the treatment device 712 is delivered over guide wire 766 to adesired position within the renal artery, the guide wire 766 isretracted completely from treatment device 712 and an elongate controlmember 768 (FIG. 13B) is inserted at a proximal end of the device 712and advanced distally through the elongated shaft 716 into the centrallumen 729 of the tubular support structure 722. The distal region of thecontrol member 768 can have a pre-set deployed shape (e.g., a helicalshape) when unconstrained to define the deployed state of the treatmentassembly 721. The control member 768 may be made from a super-elasticnitinol material having a pre-set or pre-formed helical shape.Alternatively, the control member can be made from a shape-memorymaterial.

The control member 768 is sufficiently elastic so as to be straightenedfor insertion at the proximal end of the device, for example, at thehandle 734. The control member 768 may be inserted directly into theelongated shaft 716. Alternatively, the control member 768 may be firsthoused inside of a more rigid insertion tube 769 (FIG. 13B) tostraighten out the control wire 768 and facilitate insertion of thecontrol member 768 into the catheter device 712. In this embodiment, thetreatment assembly 721 can be inserted into the proximal end of theelongated shaft 716 and, once located at the treatment site within therenal artery, the insertion tube 769 can be retracted to allow thecontrol member 768 to deploy. As shown in FIG. 13B, the control member768 imparts a force on the tubular support structure 722, therebydeforming it in to an expanded helical configuration and deploying thetreatment assembly 721 to locate the energy delivery elements 724against the wall of the renal artery.

In a particular embodiment, a plurality of electrical delivery elements724 are configured as multiple electrodes 724 mounted onto a flexible,somewhat distensible tube 722 (e.g., a tube made of polyethylene blockamide copolymer such as PEBAX® 5533D, or a lower durometer material). Inother embodiments, the tubular support structure 722 may be constructedfrom other polymers, e.g., PET, polyamide, polyimide, PEBAX,polypropylene, or PEEK polymers that provide the desired flexibility. Inone embodiment, the tubular support structure 722 has an inner diameterof about 0.03 inch (0.76 mm) and an outer diameter of about 0.04 inch(1.02 mm) and a length of about 4 cm. The electrodes 724 can becylindrical electrodes and, in one embodiment, can have an innerdiameter of about 0.042 inch (1.07 mm), an outer diameter of about 0.046inch (1.17 mm), and a length of about 1 mm. The electrodes 724 can bespaced between 3 to 5 mm apart and bonded to the tubular supportstructure 722 using an adhesive. Electrode conductive power supply wires725 can extend proximally along and outside the tubular supportstructure 722.

In several embodiments, the proximal end 722 b of the flexible supportstructure 722 with the electrodes 724 is placed over the distal end oftubular elongated shaft 716 and bonded in place. The elongated shaft716, for example, can include a polyamide tube. In one embodiment, theshaft 716 has an inner diameter about of 0.025 inch (0.64 mm) and anouter diameter of about 0.03 inch (0.76 mm) with a length of about 100cm. In other embodiments, the elongated shaft has an inner diameter of0.026 inch (0.66 mm) and an outer diameter of 0.028 inch (0.71 mm)and/or other suitable dimensions. An outer tubular jacket 717 cansurround the shaft 716 and abut or overlap the proximal end 722 a of thetubular support structure 722.

The control member 768 for deploying the treatment assembly 721 caninclude, for example, a nitinol wire pre-shaped with a helicalconfiguration over the distal region of the control member 768. In oneembodiment, the control member 768 has a diameter of about 0.015 inch(0.38 mm) and tapers distally to a tip having a diameter of 0.008 inch(0.20 mm). Several different diameters of pre-shaped control members 768can be made to accommodate different diameter renal arteries with eachhaving a diameter ranging from about 4.0 mm to about 8.0 mm. The controlmember 768 can have a shape memory transformation temperature that isslightly above body temperature (e.g., austenite finish temperatureA_(f)=42° C.). The control member 768 is more pliable at temperaturesbelow the A_(f)<, and therefore the helical region can be straightenedmanually with relative ease. Accordingly, the control member 768 canthen be inserted directly into the proximal end of the catheter withoutthe need for the “rigid insertion tube 769.” Once the distal region ofthe control member 768 is positioned within the tubular supportstructure 722 surrounded by the multiple electrodes 824, raising thetemperature of the shape memory control member 768 above the A_(f) willallow it to assume the helical configuration, deform the tubular supportstructure 722 and press the electrodes 724 into the arterial wallallowing the tissue ablation to occur. Once the ablation is completedand the energy source 26 turned off, the surrounding blood flow can coolthe electrodes 724 and the control member 768 below the A_(f), allowingthe control member 768 to become more pliable for removal from thecatheter. Those skilled in the art will understand that various methodscan be used to heat the control member 768 to transform its shape.

In the embodiment illustrated in FIG. 13B, the control member 768 isdisposed in the optional insertion tube 769. The insertion tube 769 canbe made from a variety of materials including braided polyimide, PEEK,and/or stainless steel and can have dimensions such that the insertiontube 769 can slide easily through the elongated shaft 716. Thepre-shaped control member 768 has a total axial delivery length that isgreater that then the axial length of the insertion tube 769 such thatthe guide wire 766 can be advanced and retracted from the proximal endof the catheter device 712.

In the above described embodiments that use the flexible tubular supportstructure 722 and the insertion tube 769 for delivery and deployment ofthe therapeutic assembly, the guide wire is completely removed from thetubular support structure 722 before insertion of the pre-shaped controlmember 768 because there is only a single lumen in the elongated shaftof the catheter for receiving the guide wire 766 and the control member768. Further embodiments of treatment devices, however, include for anelongated shaft with multiple lumens to provide multiple passageways inwhich to hold a control member, a guide wire, supply wires, and/or aninjectable fluid (e.g., contrast, medicine, or saline). Accordingly,such treatment devices provide for an over-the-wire delivery anddeployment of a treatment assembly with an insertable member without theneed to remove the guide wire completely from the catheter.

FIGS. 14A and 14B, for example, are broken longitudinal cross-sectionalviews of a treatment device 812 configured in accordance with anotherembodiment of the present technology. As shown in FIG. 14A, thetreatment device 812 includes a treatment assembly 821 having aplurality of energy delivery elements 824 carried by a relativelyflexible tubular support structure 822 defining a central lumen 829. Thetubular support structure 822 includes a distal end 822 a having anaxial opening 823 for passage of a guide wire 866 extending through thecentral lumen 829. The tubular support structure 822 has a proximal end822 b coupled or affixed to the distal end of an elongated tubular shaft816. The elongated shaft 816 can define a first internal lumen 813 forhousing the guide wire 866. The guide wire 866 exits proximally from aconventional hub/luer fitting located, for example, at the handle 834.Accordingly, the illustrated configuration provides for an OTW deliveryfrom the access site to the treatment site. Inserting the substantiallystraight guide wire 866 through the flexible tubular support structure822 straightens the tubular support structure 822 so as to place thetreatment assembly 821 into a low profile delivery state for delivery tothe treatment site in the renal artery.

The tubular shaft 816 further includes a second internal lumen 814 forhousing a control member 868 for deployment of the treatment assembly821. The tubular shaft 816 may have multiple lumens to hold the shapeinsertion members, supply wires, and/or an injectable fluid (e.g.,contrast, medicine, or saline). FIGS. 14A and 14B show the two lumens813, 814 formed within the integral tubular shaft 816. Alternatively,the first and second lumens 813 and 814 can be defined by separatetubular shafts disposed within the outer tubular shaft 816. Within thesecond internal lumen 814 of the tubular shaft 816, the control member868 can be maintained in a substantially linear configuration. Once thetreatment device 812 is placed in a desired position within a renalartery, the guide wire 866 can be retracted from the tubular supportstructure 822 into the first lumen 813, and the control member 868 canbe advanced distally into the central lumen 829 of the tubular supportstructure 822. Because each of the control member 868 and the guide wire866 have independent lumens in which they reside, the guide wire 866needs only be retracted a sufficient distance proximally to exit thetubular support structure 822 of the treatment assembly 821 so as toallow the control member 868 to fill the support structure 822 anddeploy the treatment assembly 821. In several embodiments, for example,the guide wire 866 can be retracted 10-20 cm (e.g., about 15 cm) toclear the tubular support structure 822 for deployment of the treatmentassembly 821.

The control member 868 can have a pre-set deployed shape that defines ahelical shape when unconstrained to define the deployed state of thetreatment assembly 821. The control member 868 may be made from asuper-elastic nitinol material having a pre-set helical shape. Oncelocated within the support structure 822, the elastic control member 868can impart a force on the tubular support structure 822 deforming it into an expanded helical configuration (e.g., as shown in FIG. 14B), so asto deploy the treatment assembly 821 and locate the energy deliveryelements 824 against the wall of the renal artery.

In other embodiments of the device with the multi-lumen elongated shaft,a tubular support structure can include at least two or more independentlumens or passageways. For example, FIGS. 14C and 14D illustrate atreatment device 912 including a treatment assembly 921 with a pluralityof energy delivery elements 924. A tubular support structure 922 definesat least two internal lumens. A first lumen 928 can include an axialopening at its distal end and can be adapted to accept a guide wire 966having a diameter of less than about 0.015 inch (0.38 mm) for insertionand retraction from the first lumen 928. Accordingly, the supportstructure 922 can be delivered into a renal artery using an OTW approachas discussed above. In other embodiments, the distal end 922 a of thetubular support structure 922 may terminate in a rounded distal tip tofacilitate atraumatic insertion of the treatment device into the renalartery. A second lumen 930 is adapted to hold a deployment member 968having a pre-set distal region defining a helical shape in a deployedstate.

The therapeutic assembly 921 can be placed into a low-profile deliverystate (e.g., as shown in FIG. 14C) by inserting the guide wire 966through the first lumen 928 of the support structure 922 for delivery toa renal artery. The substantially linear guide wire 966 can overcome thepre-set helical shape in the flexible deployment member 968 to maintainthe therapeutic assembly 921 in the delivery state. The guide wire 966may be of a constant stiffness along its length or, alternatively, mayhave a variable stiffness or flexibility along its length so as toprovide increased stiffness, for example, in the proximal to distaldirection. Once the treatment assembly 921 is positioned at the targettreatment site in the renal artery, the therapeutic assembly 921 can bedeployed by retracting the guide wire 966 out of the first lumen 928 ofthe support structure 922 such that it is generally located within theelongated shaft 916 (e.g., within one of the plurality of lumens formedwithin the elongated shaft 916). With the guide wire 966 removed fromthe support structure 922, the deployment member 968 can impart adeforming force on the tubular support structure 922 that deforms it tothe helical shape so as to deploy the therapeutic assembly 921 (e.g., asshown in FIG. 14D). Accordingly, the guide wire 966 provides a controlmember to alter the therapeutic assembly between the delivery and thedeployed states. Optionally, the first lumen 928 may be used to delivera fluid distally, such as saline to cool the energy delivery element 924during energy delivery.

In another embodiment, the deployment member 968 may be retractable tocontrol the delivery and deployment states of the treatment assembly 921and the guide wire 966 or other straightening stylet can remain in thefirst lumen 928 during deployment. In such an arrangement, the guidewire 966 can be sufficiently rigid to place the treatment assembly 921in the low profile configuration for delivery, yet flexible enough toallow the deployment member 968 to impart a force on the assembly 921 toplace the support structure 922 and the treatment assembly 921 in thedeployment configuration.

FIGS. 15A and 15B illustrate still another embodiment a treatment device1012 that allows a guide wire 1066 to remain at least partially insertedin an elongated shaft 1016 during treatment. As shown in FIG. 15A, thetreatment device 1012 includes a single lumen in each of a tubularsupport structure 1022 and the elongated shaft 1016. The treatmentdevice 1012 includes a treatment assembly 1021 having a plurality ofenergy delivery elements 1024 mounted to the tubular support structure1022 defining a single central lumen 1029. The support structure 1022may be covered with an electrical insulator, e.g., with a heat shrinktube of a polymer such as PET.

The tubular support structure 1022 may also include a distal end 1022 ahaving an axial opening 1023 to allow the guide wire 1066 to projectbeyond the distal end 1022 a. In some embodiments, the distal end 1022 amay terminate in a rounded distal portion (e.g., as shown in brokenlines). The tubular support structure 1022 can have a proximal end 1022b coupled to the distal end of the elongated shaft 1016. The centrallumen 1029 of the support structure 1022 can extend through theelongated shaft 1016 to receive the guide wire 1066 and allow for an OTWdelivery. In operation, inserting the substantially straight guide wire1066 through the tubular support structure 1022 straightens the tubularsupport structure 1022 so as to place the treatment assembly 1021 into alow-profile delivery state (e.g., as shown in FIG. 15A) for delivery tothe treatment site in the renal artery.

The tubular support member 1022 may be made from an elastic or superelastic material, e.g., nitinol tubing or polymer-composite tubingincluding braided or coiled filaments of nitinol. In severalembodiments, the support structure 1022 can have an inner diameter lessthan or equal to about 0.015 inch (0.38 mm), e.g., about 0.010 inch(0.25 mm), and a wall thickness of less than about 0.005 inch (0.13 mm),e.g., about 0.003 inch (0.76 mm). The tubular support structure 1022 mayalso be made from a shape-memory material, e.g., nitinol having apre-formed helical deployed shape. As an alternative to using apre-formed shape, the tubular support structure 1022 may includes apre-shaped inner member (e.g., inner tubing) or an outer frame structure(not shown) that biases the tubular support structure 1022 into thehelical deployment configuration.

With the guide wire 1066 disposed in the central lumen 1029, the guidewire 1066 imparts a straightening force on the tubular support structure1022 so as to define the low profile or collapsed delivery configurationshown in FIG. 15A. The guide wire 1066 may be of a constant stiffnessalong its length or, alternatively, may have a variable stiffness orflexibility along its length so as to provide increased flexibility(e.g., in the proximal to distal direction). To deploy the treatmentassembly 1021, the guide wire 1066 can be retracted proximally into theelongated shaft 1016 so as to remove the guide wire 1066 from thesupport structure 1022. As shown in FIG. 15B, in the absence of astraightening force, the support structure 1022 can deploy into ahelical configuration. Accordingly, the guide wire 1066 acts as acontrol member for altering the configuration of the treatment assembly1021 between the delivery and the deployed states.

Although the embodiments of the treatment or catheter devices previouslydescribed include an arrangement of the treatment assembly and a controlmember to place the assembly in a low-profile delivery state, thecatheter devices may further include an external sheath that can bedisposed and retracted over the treatment assembly to alter its deliveryand deployed configurations. For example, as shown in FIGS. 16A and 16B,a treatment device 1212 can be used in conjunction with a deliverysheath 1291 that forms a sheath around a treatment assembly 1221 and anelongated shaft 1216. As noted, in certain embodiments, it may beadvantageous to use a guide catheter 1290 of a particular size tofacilitate insertion of the treatment device 1221 through the femoralartery. A delivery sheath 1291 may be used in conjunction with the guidecatheter 1290 to gain access to a renal artery and deliver a containedexpandable helical structure 1222. Alternatively, the delivery sheath1291 may be used in conjunction with a guide wire (not shown) asdescribed previously. When used in conjunction with the guide catheter1290, a working length of the elongated shaft 1216 may be about 40 cm toabout 125 cm. If, for example, a 55 cm length guide catheter is used,then this working length may be about 70 cm to about 80 cm. If a 90 cmlength guide catheter 1290 is used, then this working length may beabout 105 cm to about 115 cm. In a representative embodiment where noguide catheter 1290 is used, then this working length may be about 40 cmto about 50 cm. In still other embodiments, a variety of other differentdimensions and/or arrangements may be used.

In the depicted embodiment, the treatment assembly 1221 includes ahelical structure 1222 that may be held in a low profile deliveryconfiguration by the delivery sheath 1291. Removal of the deliverysheath 1291 allows the helical support structure 1222 to deploy andplace the energy delivery elements 1224 into contact with the wall ofthe renal artery. The deployment of the support structure 1222 may bepassive (e.g., the structure has a pre-set deployed shape) or active(e.g., the deployment is facilitated by a pre-shaped stylet or a tensionwire). Regardless of the type of expansion, the helical supportstructure 1222 may by coupled to a control member (e.g., a control wire)that compresses the helical structure prior to removal or repositioningof the treatment device 1212. In particular embodiments, depending onthe placement and number of energy delivery elements 1224, the helicalsupport structure 1222 may be progressively repositioned within therenal artery to provide a plurality of locations for energy delivery.FIG. 16B shows the embodiment of a catheter with a helical structure1222 of FIG. 16A with the delivery sheath 1291 retracted allowing thehelical structure 22 to elastically expand to its deployed configurationin a renal artery. It should be noted that, in FIG. 16A, the sheath 1291and treatment assembly 1221 are drawn oversized for clarity.

In one particular embodiment, a sheath can be used to hold thecomponents of the treatment assembly together, particularly as thedevice is navigated through to the treatment site within the renalartery. With reference to FIGS. 9A and 9B, the treatment assembly 221can include a spine or support structure 222 of nitinol material with aplurality of electrodes 224 disposed thereabout. The nitinol supportstructure 222 can be helically wrapped about a braided polyamide innermember 268. In the delivery state of the treatment assembly 221 of FIG.9B, the support structure 222 may lie adjacent to the inner member 268over its length. In order to minimize substantial separation between thesupport structure 222 and the inner member 268 when the treatmentassembly 221 is bent or curved during delivery, a sheath can be disposedover the treatment assembly 221. Sheaths may also be employed with thetreatment assemblies described above with reference to FIGS. 10A-11B andother suitable treatment assemblies described herein.

A sheath may also be used to support a treatment assembly in itsdelivery configuration, even when the treatment assembly has ashape-forming insertion member disposed in the lumen of the flexibletubular support structure. For example, with reference to FIGS. 13A and13B, a sheath (not shown) can be disposed over support structure 722.Upon retraction of the guide wire 766 and insertion of a control member768 into the lumen of the support structure 722, the sheath prevents thetreatment assembly 721 from deploying to its fullest transversedimension. To permit the assembly 721 to deploy completely to thedesired helical configuration, the sheath can be retracted.Alternatively or in addition, the tubular support structure 722 ispreferable stiff enough to allow for guidable insertion to the treatmentsite without the use of the stylet or shaping member, but flexibleenough to take on the shape of the inserted control member 768 once thesheath is withdrawn. Further, in the alternative or in addition to, theinsertable control member 768 can be sheathed to minimize or eliminatethe premature deployment of the treatment assembly upon insertion of thecontrol member. Accordingly, once the sheath is removed, the insertionmember 768 can expand to its full deployment configuration.

In still further embodiments with reference to FIGS. 13A and 13B, thestylet 768 is positioned in the distal end treatment assembly 721 of thedevice 712 while the device is at the treatment site (e.g., within therenal artery). In this embodiment, for example, the stylet 768 issheathed in a low-profile configuration during insertion by insertiontube 769. The insertion tube 769 is removed from the pre-formed stylet768 after insertion, allowing the stylet 768 to take its helical shapein the manner described above. In this embodiment, the stylet 768 canprovide structure and a desired level of rigidity to the device 712 tohelp guide and position the device 712 during delivery and then give itthe desired helical arrangement upon deployment.

In some of the over-the-wire embodiments of the treatment catheterdevice described above, the guide wire is described as extending withinthe elongated shaft of the catheter from at least the distal end of thetreatment assembly to a location proximal of the handle assembly. Inorder to disengage the catheter from the guide wire requires retractingthe full length of the guide wire proximally from the access site.Accordingly, the guide wire axial length may be greater than that of thecatheter elongated shaft and its distal treatment assembly. To providefor an operation and manipulation of a shorter guide wire, and inparticular to minimize the retraction distance to disengage the catheterfrom the guide wire, it may be desirable to have a treatment catheterdevice that provides for a rapid-exchange configuration. The rapidexchange examples described below with reference to FIGS. 17A-17E mayalso be used with any of the treatment devices described herein thatemploy a guide wire and OTW delivery techniques.

FIG. 17A, for example, is a broken side view in part section of a distalportion of a treatment device 1410 with a rapid exchange configurationin accordance with an embodiment of the technology. The treatment device1410 includes a treatment assembly 1421 helically disposed about atubular control member 1468 that defines an internal lumen for passageover a guide wire 1466. The tubular control member 1468 extendsproximally within the elongated shaft 1416 of the treatment device 1410,which is shown at least partially disposed within a guide catheter 1490.To provide for a rapid exchange configuration in which the guide wire1466 extends at least partially parallel to and externally to theelongated shaft 1416, the tubular control member 1468 includes anopening 1470 proximal to the treatment assembly 1421, but distal of ahandle assembly (not shown) for exit of the guide wire 1466. Theelongated shaft 1416 also preferably includes an opening 1472 for exitof the guide wire 1466 and passage into the guide catheter 1490. Becausethe guide wire 1466 does not need to extend proximally through theelongated shaft 1416 to the handle assembly (not shown), its overalllength can be reduced.

FIGS. 17B and 17C illustrate another embodiment of a treatment device1600 with a rapid exchange configuration in accordance with anotherembodiment of the technology. More specifically, FIG. 17B is a brokenside view in part section of a distal portion the treatment device 1600in a delivery state, and FIG. 17C is a broken side view of the treatmentdevice 1600 in a deployed state. Referring to FIGS. 17B and 17Ctogether, the treatment device 1600 includes a treatment assembly 1621having a tubular support structure 1622 with a plurality of energydelivery elements 1624 disposed about the support structure 1622. Thesupport structure 1622 extends proximally within at least a portion ofthe elongated shaft 1616 of the treatment device 1600. Energy supplywires 1625 preferably extend within the tubular support structure 1622to provide energy from an external generator source (not shown) to eachof the energy delivery elements 1624. The tubular support structure 1622extends distally about a tubular member 1680 in a spiral or helicalmanner and terminates along an outer surface of the tubular member 1680and is preferably bonded at a distal region 1680 a of the tubular member1680.

The tubular member 1680 provides the treatment assembly 1621 with aninner member disposed within the helix defined by the support structure1622 that can be used to control the distal region of the supportstructure 1622 to alter the support structure 1622 of the treatmentassembly 1621 between a delivery and a deployed configuration. Thetreatment device 1600 further includes a control member 1668 coupled toa proximal region of the tubular member 1680 for pushing distally andpulling proximally the inner member 1680 so as to move respectively thedistal end 1622 a of the tubular support structure 1622 in the distaland proximal directions with respect to the distal end of the shaft1616. Distal movement of the distal end 1622 a of the support structure1622 lengthens an axial length of the helical shaped support structure1622 and places the treatment assembly 1621 in the deliveryconfiguration (as seen in FIG. 17B). Likewise, proximal movement of thedistal end 1622 a of the support structure 1622 shortens an axial lengthof the helical shaped support structure 1622 to place the treatmentassembly 1621 in the deployed configuration shown in FIG. 17C. In oneembodiment, the control member 1668 may be configured as a push-pullrod. For example, the push-pull rod can extend axially within theelongated shaft 1616 and, in some embodiments, within an independentlumen in the elongated shaft 1616 separate from a lumen carrying powersupply wires 1625 for the treatment assembly 1621.

The tubular inner member 1680 defines a internal lumen for passage of aguide wire 1666. Accordingly, the tubular inner member 1680 includes anaxial opening at a distal end region 1680 a for passage of the guidewire 1666. The proximal end region 1680 b of the tubular inner member1680 is configured for a proximal passage and exit of the guide wire1666. The proximal region 1680 b may terminate, for example, in anoblique elongated opening 1682 for exiting of the guide wire 1666. Insome embodiments, the proximal region 1680 b of the inner member 1680may be affixed to the distal end of the push-pull member 1668 such thatthe push-pull member 1668 can control the axial distance between theguide wire exit 1682 and the elongated shaft 1668. Further, in someembodiments the distal end of the push-pull member 1668 may include ataper or angled end to increase the cross-sectional area of thepush-pull member 1668 for bonding to the inner tubular member 1680.Because the arrangement of the inner member 1680 and the push-pullmember 1668 maintains the guide wire exit opening external to theelongated shaft 1616, the arrangement provides for a rapid exchangeconfiguration.

In particular, the guide wire exit opening 1682 provides that the guidewire 1666 can extend parallel and external to the elongated shaft 1616.Thus, manipulation of the guide wire 1666 does not require that theguide wire 1666 extend proximally within the full length of theelongated shaft 1616 and beyond, for example, through a handle assembly.Accordingly, in some embodiments the guide wire length 1666 may have areduced length, e.g., about 180 cm. Moreover, to the extent it may bedesired to disengage the treatment assembly 1621 from the guide wire1666, the guide wire 1666 need only be retracted an amount sufficient toproximally retract the distal end of the guide wire from the guide wireexit opening 1682.

In one embodiment, the elongated shaft 1616 is configured to engage theproximal region of the inner tubular member 1680 in the deployedconfiguration of the treatment assembly 1621. More specifically, thedistal region of the elongated shaft 1616 is formed so as to form amating fit with the external portion of the proximal end 1680 b of thetubular member 1680 in the deployed configuration. As shown in FIG. 17C,the push-pull member 1668 is fully retracted so as to deploy thetreatment assembly 1621. The retraction of the push-pull member 1668locates the proximal end 1680 b adjacent the distal end of elongatedshaft 1616. The distal end of the elongated shaft 1616 preferablyincludes a taper such that the internal lumen for the energy supplywires 1625 and the linear portion of the tubular support structure 1622extend distally beyond the internal lumen which houses the push-pullmember 1668. The taper (e.g., skived or oblique notch) at the distal endof the elongated shaft 1616 is sized and shaped to receive the proximalend 1680 b of the inner tubular member when located adjacent theelongated shaft 1616.

In one embodiment, the treatment assembly 1621 may have a maximumdelivery length ranging from, for example, about 8 mm to about 50 mm,e.g., about 15 mm to about 50 mm. In a deployed configuration, thetreatment assembly 1621 may have a maximum axial length of, e.g., about45 mm. The tubular member 1680 may have an axial length ranging fromabout 2-50 cm. with an opening 1682 having an axial length of, e.g.,about 2-8 mm. The push-pull rod 1668 may be configured to alter theaxial distance between the distal end of the elongated shaft 1616 andthe opening 1682 of the inner tubular member 1680 over a distance of,e.g., 1 mm to about 30 mm. The elongated shaft 1616 and the guide wire1666 may extend parallel to one another within a surrounding guidecatheter 1690. The catheter device 1612 can be configured such that theopening 1682 is located inside or outside the guide catheter 1690.

An alternate embodiment of the treatment device 1710 is shown in FIG.17D. In this embodiment, the treatment assembly 1721 includes a tubularsupport structure 1722 having a proximal portion that extends proximallyinto the elongated shaft to carry the energy supply wires for the energydelivery elements 1724 disposed about the support structure 1722.Extending parallel to the proximal portion of the tubular supportstructure 1722 are a control member 1768 that includes a push-pull rod.Also preferably extending parallel to the push-pull control member 1768is a tubular member 1780 defining an internal lumen for passage of aguide wire 1766. Each of the distal end region 1722 a of the supportstructure 1722 and the pull-push rod member 1768 is preferably affixedto the tubular member 1780 such that axial movement of the push-pullmember 1768 moves the distal end of the tubular support structure 1722and the tubular member 1780 along the guide wire 1766. The tubularsupport structure 1722 is preferably helically wrapped about the tubularmember 1780 such that the tubular member 1780 is internal to the helixdefined by the support member 1722. The distal and proximal movement ofthe distal region 1722 a respectively extends and reduces the axiallength of the helical tubular support structure 1722 to place thetreatment assembly 1721 in the delivery and deployed configurations.Proximal of the treatment assembly 1721, distal of the handle assemblyalong the tubular member 1780 is an opening 1782 to provide for a rapidexchange configuration.

Because the push-pull member 1768 and the distal end 1722 a of thetubular support structure are affixed to the tubular member 1780, thetubular support structure 1722 cannot be rotated about the tubularmember 1780 and its axial opening through which the guide wire passes.Accordingly, to provide for a distal end 1722 a that rotates about theguide wire lumen of the member 1780, the push-pull member 1768 and thedistal end 1722 a of the tubular support member 1722 a are coupled tobut separable from the tubular member 1780 as seen for example, in FIG.17E. More specifically the tubular member 1780 is preferably detachableor independently rotatable with respect to the tubular support structure1722 and the push-pull member 1768. Accordingly, a rotatable distalregion of the treatment assembly 1721 is rotatable about the guide wire1766. Moreover, because the distal region of the treatment assembly 1721is rotatable about the tubular member 1780, the proximal guide wire exit1782 can remain fixed relative to the treatment assembly 1721 such thatthe rapid exchange configuration does not interfere with rotation of thetreatment assembly.

In the embodiment shown in FIG. 17E, a sleeve 1785 is provided to whichthe distal end of the tubular support structure 1722 and the push-pullmember 1768 are affixed. The sleeve 1785 further defines an internalpassage for slidably receiving the member 1780. The sleeve 1785 providesfor a tip assembly of the treatment assembly which axially slides androtates about the tubular member 1780. The configuration furtherprovides rotation of the support structure 1722 and the push-pull member1768 of the assembly relative to the tubular member 1780 whilemaintaining the preferably generally helical shape without the supportstructure 1722 “wrapping up” around the tubular member 1780 and losingthe desired shape/configuration while manipulating the treatmentassembly within the vessel.

IV. Applying Energy to Tissue Via the Energy Delivery Element

Referring back to FIG. 1, the energy generator 26 may supply acontinuous or pulsed RF electric field to the energy delivery elements24. Although a continuous delivery of RF energy is desirable, theapplication of RF energy in pulses may allow the application ofrelatively higher energy levels (e.g., higher power), longer or shortertotal duration times, and/or better controlled intravascular renalneuromodulation therapy. Pulsed energy may also allow for the use of asmaller electrode.

Although many of the embodiments described herein pertain to electricalsystems configured for the delivery of RF energy, it is contemplatedthat the desired treatment may be accomplished by other means, e.g., bycoherent or incoherent light; direct thermal modification (e.g., with aheated or cooled fluid or resistive heating element or cryogenicapplicator); microwave; ultrasound (including high intensity focusedultrasound); diode laser; radiation; a tissue heating fluid; and/or acryogenic refrigerant.

As previously discussed, energy delivery may be monitored and controlledvia data collected with one or more sensors, such as temperature sensors(e.g., thermocouples, thermistors, etc.), impedance sensors, pressuresensors, optical sensors, flow sensors, chemical sensors, etc., whichmay be incorporated into or on the energy delivery elements 24, thesupport structure 22, and/or in/on adjacent areas on the distal portion20. A sensor may be incorporated into the energy delivery element(s) 24in a manner that specifies whether the sensor(s) are in contact withtissue at the treatment site and/or are facing blood flow. The abilityto specify sensor placement relative to tissue and blood flow is highlysignificant, since a temperature gradient across the electrode from theside facing blood flow to the side in contact with the vessel wall maybe up to about 15° C. Significant gradients across the electrode inother sensed data (e.g., flow, pressure, impedance, etc.) also areexpected.

The sensor(s) may, for example, be incorporated on the side of one ormore energy delivery elements 24 that contact the vessel wall at thetreatment site during power and energy delivery or may be incorporatedon the opposing side of one or more energy delivery elements 24 thatface blood flow during energy delivery, and/or may be incorporatedwithin certain regions of the energy delivery elements 24 (e.g., distal,proximal, quandrants, etc.). In some embodiments, multiple sensors maybe provided at multiple positions along the electrode or energy deliveryelement array and/or relative to blood flow. For example, a plurality ofcircumferentially and/or longitudinally spaced sensors may be provided.In one embodiment, a first sensor may contact the vessel wall duringtreatment, and a second sensor may face blood flow.

Additionally or alternatively, various microsensors may be used toacquire data corresponding to the energy delivery elements 24, thevessel wall and/or the blood flowing across the energy delivery elements24. For example, arrays of micro thermocouples and/or impedance sensorsmay be implemented to acquire data along the energy delivery elements 24or other parts of the treatment device. Sensor data may be acquired ormonitored prior to, simultaneous with, or after the delivery of energyor in between pulses of energy, when applicable. The monitored data maybe used in a feedback loop to better control therapy, e.g., to determinewhether to continue or stop treatment, and it may facilitate controlleddelivery of an increased or reduced power or a longer or shorterduration therapy.

V. Blood Flow Around the Energy Delivery Elements

Non-target tissue may be protected by blood flow within the respectiverenal artery that serves as a conductive and/or convective heat sinkthat carries away excess thermal energy. For example, referring to FIGS.1 and 18 together, since blood flow is not blocked by the elongatedshaft 16, the helically-shaped therapeutic assembly 21, and the energydelivery elements 24 it carries, the native circulation of blood in therespective renal artery serves to remove excess thermal energy from thenon-target tissue and the energy delivery element. The removal of excessthermal energy by blood flow also allows for treatments of higher power,where more power may be delivered to the target tissue as thermal energyis carried away from the electrode and non-target tissue. In this way,intravascularly-delivered thermal energy heats target neural fiberslocated proximate to the vessel wall to modulate the target neuralfibers, while blood flow within the respective renal artery protectsnon-target tissue of the vessel wall from excessive or undesirablethermal injury.

It may also be desirable to provide enhanced cooling by inducingadditional native blood flow across the energy delivery elements 24. Forexample, techniques and/or technologies may be implemented by theclinician to increase perfusion through the renal artery or to theenergy delivery elements 24 themselves. These techniques includepositioning partial occlusion elements (e.g., balloons) within upstreamvascular bodies such as the aorta, or within a portion of the renalartery to improve flow across the energy delivery element.

FIG. 18, for example, illustrates hypothetical blood flow in a renalartery. Blood flow (F) is thought to be laminar, e.g., to exhibit agradient of flow rates such that in an area closest to the center of theartery, e.g., area 2214, the blood flow F may be faster relative toareas closer to the renal artery wall 55, e.g., areas 2215. Accordingly,the blood flow F nearest the location of the energy delivery elements 24is relatively slow. Because cooling of the energy delivery elements 24is mediated by blood flow, improved cooling may be achieved byredirecting the blood flow F in the renal artery so that the bloodflowing around the energy delivery elements 24 is relatively faster.

FIG. 19A illustrates an embodiment in which a fluid redirecting element2220 is positioned within the center of the renal artery. Accordingly,the flowing blood, represented by arrows 2216, including faster flowingblood, is redirected towards the energy delivery elements 24. The fluidredirecting element may be any biocompatible material, such as apolymer, that is positioned to encourage blood flow towards the energydelivery elements 24 carried by a mesh structure 3422.

Referring to FIGS. 19A and 19B together, the fluid redirecting element2220 may extend from the distal end region 20 of the elongated shaft 16,generally along the axis A-A of the elongated shaft 16. For embodimentsin which a guide wire (not shown) is used, the fluid redirecting element2220 may include an integral passage (not shown) of an inner membersized and shaped to accommodate the guide wire. In addition, in someembodiments, an axial length of the fluid redirecting element 2220 maybe at least 25%, at least 50%, or at least 75% of an axial length of themesh structure 2220 in the expanded configuration. In any case, in orderto maximize redirected blood flow, the fluid redirecting element 2220may extend at least far enough into the mesh structure 3422 so that animaginary axis through the energy delivery elements 24 and orthogonal tothe axis A-A intersects the fluid redirecting element 2220. The diameter2228 of the fluid redirecting element 2220 may be expandable such thatin its unexpanded state it is generally compatible with insertion,repositioning, and removal of the mesh structure 3422 and in itsexpanded state it is configured to redirect blood flow toward areascloser to the renal artery wall, e.g., areas 2215. As shown in FIG. 19B,in a collapsed configuration, the mesh structure 3422 may conform to theshape of the fluid redirecting element 2220. The diameter 2228 may beslightly larger than, about equal to, or less than a diameter of theelongated shaft 16. In one embodiment, the diameter 2228 may be lessthan about 2.18 mm.

In addition, or as an alternative, to passively utilizing blood flow asa heat sink, active cooling may be provided to remove excess thermalenergy and protect non-target tissues. For example, a thermal fluidinfusate may be injected, infused, or otherwise delivered into thevessel in an open circuit system. Thermal fluid infusates used foractive cooling may, for example, include (room temperature or chilled)saline or some other biocompatible fluid. The thermal fluid infusate(s)may, for example, be introduced through the treatment device 12 via oneor more infusion lumens and/or ports. When introduced into thebloodstream, the thermal fluid infusate(s) may, for example, beintroduced through a guide catheter at a location upstream from theenergy delivery elements 24 or at other locations relative to the tissuefor which protection is sought. The delivery of a thermal fluid infusatein the vicinity of the treatment site (via an open circuit system and/orvia a closed circuit system) may, for example, allow for the applicationof increased/higher power treatment, may allow for the maintenance oflower temperature at the vessel wall during energy delivery, mayfacilitate the creation of deeper or larger lesions, may facilitate areduction in treatment time, may allow for the use of a smallerelectrode size, or a combination thereof.

Accordingly, treatment devices configured in accordance with embodimentsof the technology may include features for an open circuit coolingsystem, such as a lumen in fluid communication with a source of infusateand a pumping mechanism (e.g., manual injection or a motorized pump) forinjection or infusion of saline or some other biocompatible thermalfluid infusate from outside the patient, through elongated shaft 16 andtowards the energy delivery elements 24 into the patient's bloodstreamduring energy delivery. In addition, the distal end region 20 of theelongated shaft 16 may include one or more ports for injection orinfusion of saline directly at the treatment site.

VI. Use of the System

A. Intravascular Delivery, Deflection and Placement of the TreatmentDevice

As mentioned previously, any one of the embodiments of the treatmentdevices described herein may be delivered using OTW or RX techniques.When delivered in this manner, the elongated shaft 16 includes a passageor lumen accommodating passage of a guide wire. Alternatively, any oneof the treatment devices 12 described herein may be deployed using aconventional guide catheter or pre-curved renal guide catheter (e.g., asshown in FIGS. 3A and 3B). When using a guide catheter, the femoralartery is exposed and cannulated at the base of the femoral triangle,using conventional techniques. In one exemplary approach, a guide wireis inserted through the access site and passed using image guidancethrough the femoral artery, into the iliac artery and aorta, and intoeither the left or right renal artery. A guide catheter may be passedover the guide wire into the accessed renal artery. The guide wire isthen removed. Alternatively, a renal guide catheter, which isspecifically shaped and configured to access a renal artery, may be usedto avoid using a guide wire. Still alternatively, the treatment devicemay be routed from the femoral artery to the renal artery usingangiographic guidance and without the need of a guide catheter.

When a guide catheter is used, at least three delivery approaches may beimplemented. In one approach, one or more of the aforementioned deliverytechniques may be used to position a guide catheter within the renalartery just distal to the entrance of the renal artery. The treatmentdevice is then routed via the guide catheter into the renal artery. Oncethe treatment device is properly positioned within the renal artery, theguide catheter is retracted from the renal artery into the abdominalaorta. In this approach, the guide catheter should be sized andconfigured to accommodate passage of the treatment device. For example,a 6 French guide catheter may be used.

In a second approach, a first guide catheter is placed at the entranceof the renal artery (with or without a guide wire). A second guidecatheter (also called a delivery sheath) is passed via the first guidecatheter (with or without the assistance of a guide wire) into the renalartery. The treatment device is then routed via the second guidecatheter into the renal artery. Once the treatment device is properlypositioned within the renal artery the second guide catheter isretracted, leaving the first guide catheter at the entrance to the renalartery. In this approach the first and second guide catheters should besized and configured to accommodate passage of the second guide catheterwithin the first guide catheter (i.e., the inner diameter of the firstguide catheter should be greater than the outer diameter of the secondguide catheter). For example, a 8 French guide catheter may be used forthe first guide catheter, and 5 French guide catheter may be used forthe second guide catheter.

In a third approach, a renal guide catheter is positioned within theabdominal aorta, just proximal to the entrance of the renal artery. Thetreatment device 12 as described herein is passed through the guidecatheter and into the accessed renal artery. The elongated shaft makesatraumatic passage through the guide catheter, in response to forcesapplied to the elongated shaft 16 through the handle assembly 34.

B. Control of Applied Energy

1. Overview

Referring back to FIG. 1, a treatment administered using the system 10constitutes delivering energy through the energy delivery elements orelectrodes 24 to the inner wall of a renal artery for a predeterminedamount of time (e.g., 120 sec). Multiple treatments (e.g., 4-6) may beadministered in both the left and right renal arteries to achieve thedesired coverage. A technical objective of a treatment may be, forexample, to heat tissue to a desired depth (e.g., at least about 3 mm)to a temperature that would lesion a nerve (e.g., about 65° C.). Aclinical objective of the procedure typically is to neuromodulate (e.g.,lesion) a sufficient number of renal nerves (either efferent or afferentnerves of the sympathetic renal plexus) to cause a reduction insympathetic tone. If the technical objective of a treatment is met(e.g., tissue is heated to about 65° C. to a depth of about 3 mm) theprobability of forming a lesion of renal nerve tissue is high. Thegreater the number of technically successful treatments, the greater theprobability of modulating a sufficient proportion of renal nerves, andthus the greater the probability of clinical success.

Throughout the treatment there may be a number of states that areindicative of a possibility that the treatment may not be successful. Incertain embodiments, based on indications of these states, the operationof the system 10 may be stopped or modified. For example, certainindications may result in cessation of energy delivery and anappropriate message may be displayed, such as on display 33. Factorsthat may result in a display message and/or cessation or modification ofa treatment protocol include, but are not limited to, indications of animpedance, blood flow, and/or temperature measurement or change that isoutside of accepted or expected thresholds and/or ranges that may bepredetermined or calculated. A message can indicate information such asa type of patient condition (e.g., an abnormal patient condition), thetype and/or value of the parameter that falls outside an accepted orexpected threshold, an indication of suggested action for a clinician,or an indication that energy delivery has been stopped. However, if nounexpected or aberrant measurements are observed, energy may continue tobe delivered at the target site in accordance with a programmed profilefor a specified duration resulting in a complete treatment. Following acompleted treatment, energy delivery is stopped and a message indicatingcompletion of the treatment may be displayed.

However, a treatment can be completed without initiating an indicationof an abnormal patient condition and yet an event or combination ofevents could occur that alters (e.g., decreases) the probability of atechnically successful treatment. For example, an electrode that isdelivering energy could move or be inadvertently placed withinsufficient contact between the electrode and the wall of a renalartery, thereby resulting in insufficient lesion depth or temperature.Therefore, even when a treatment is completed without an indication ofabnormal patient condition, it may be difficult to evaluate thetechnical success of the treatment. Likewise, to the extent thatindications of abnormal patient conditions may be reported by the system10, it may be difficult to understand the causes of the abnormal patientconditions (such as temperature and/or impedance values that falloutside of expected ranges).

As noted above, one or more evaluation/feedback algorithms 31 may beprovided that are executed on a processor-based component of the system10, such as one or more components provided with the generator 26. Insuch implementations, the one or more evaluation/feedback algorithms 31may be able to provide a user with meaningful feedback that can be usedin evaluating a given treatment and/or that can be used in learning thesignificance of certain types of abnormal patient conditions and how toreduce the occurrence of such conditions. For example, if a particularparameter (e.g., an impedance or temperature value) causes or indicatesthat treatment did not proceed as expected and (in some instances), mayhave resulted in a technically unsuccessful treatment, the system 10 canprovide feedback (e.g., via the display 33) to alert the clinician. Thealert to the clinician can range from a simple notification ofunsuccessful treatment to a recommendation that a particular parameterof the treatment (e.g., the impedance value(s) during treatment,placement of the energy delivery elements 24 within the patient, etc.)be modified in a subsequent treatment. The system 10 can accordinglylearn from completed treatment cycles and modify subsequent treatmentparameters based on such learning to improve efficacy. Non-exhaustiveexamples of measurements the one or more evaluation/feedback algorithms31 may consider include measurements related to change(s) in temperatureover a specified time, a maximum temperature, a maximum averagetemperature, a minimum temperature, a temperature at a predetermined orcalculated time relative to a predetermined or calculated temperature,an average temperature over a specified time, a maximum blood flow, aminimum blood flow, a blood flow at a predetermined or calculated timerelative to a predetermined or calculated blood flow, an average bloodflow over time, a maximum impedance, a minimum impedance, an impedanceat a predetermined or calculated time relative to a predetermined orcalculated impedance, a change in impedance over a specified time, or achange in impedance relative to a change in temperature over a specifiedtime. Measurements may be taken at one or more predetermined times,ranges of times, calculated times, and/or times when or relative to whena measured event occurs. It will be appreciated that the foregoing listmerely provides a number of examples of different measurements, andother suitable measurements may be used.

2. Control of Applied Energy

With the treatments disclosed herein for delivering therapy to targettissue, it may be beneficial for energy to be delivered to the targetneural structures in a controlled manner. The controlled delivery ofenergy will allow the zone of thermal treatment to extend into the renalfascia while reducing undesirable energy delivery or thermal effects tothe vessel wall. A controlled delivery of energy may also result in amore consistent, predictable and efficient overall treatment.Accordingly, the generator 26 desirably includes a processor including amemory component with instructions for executing an algorithm 30 (seeFIG. 1) for controlling the delivery of power and energy to the energydelivery device. The algorithm 30, a representative embodiment of whichis depicted in FIG. 3, may be implemented as a conventional computerprogram for execution by a processor coupled to the generator 26. Aclinician using step-by-step instructions may also implement thealgorithm 30 manually.

The operating parameters monitored in accordance with the algorithm mayinclude, for example, temperature, time, impedance, power, blood flow,flow velocity, volumetric flow rate, blood pressure, heart rate, etc.Discrete values in temperature may be used to trigger changes in poweror energy delivery. For example, high values in temperature (e.g., 85°C.) could indicate tissue desiccation in which case the algorithm maydecrease or stop the power and energy delivery to prevent undesirablethermal effects to target or non-target tissue. Time additionally oralternatively may be used to prevent undesirable thermal alteration tonon-target tissue. For each treatment, a set time (e.g., 2 minutes) ischecked to prevent indefinite delivery of power.

Impedance may be used to measure tissue changes. Impedance indicates theelectrical property of the treatment site. In thermal inductiveembodiments, when an electric field is applied to the treatment site,the impedance will decrease as the tissue cells become less resistive tocurrent flow. If too much energy is applied, tissue desiccation orcoagulation may occur near the electrode, which would increase theimpedance as the cells lose water retention and/or the electrode surfacearea decreases (e.g., via the accumulation of coagulum). Thus, anincrease in tissue impedance may be indicative or predictive ofundesirable thermal alteration to target or non-target tissue. In otherembodiments, the impedance value may be used to assess contact of theenergy delivery element(s) 24 with the tissue. For multiple electrodeconfigurations (e.g., when the energy delivery element(s) 24 includestwo or more electrodes,) a relatively small difference between theimpedance values of the individual electrodes may be indicative of goodcontact with the tissue. For a single electrode configuration, a stablevalue may be indicative of good contact. Accordingly, impedanceinformation from the one or more electrodes may be provided to adownstream monitor, which in turn may provide an indication to aclinician related to the quality of the energy delivery element(s) 24contact with the tissue.

Additionally or alternatively, power is an effective parameter tomonitor in controlling the delivery of therapy. Power is a function ofvoltage and current. The algorithm 30 may tailor the voltage and/orcurrent to achieve a desired power.

Derivatives of the aforementioned parameters (e.g., rates of change)also may be used to trigger changes in power or energy delivery. Forexample, the rate of change in temperature could be monitored such thatpower output is reduced in the event that a sudden rise in temperatureis detected. Likewise, the rate of change of impedance could bemonitored such that power output is reduced in the event that a suddenrise in impedance is detected.

As seen in FIG. 20, when a clinician initiates treatment (e.g., via thefoot pedal 32 illustrated in FIG. 1), the control algorithm 30 includesinstructions to the generator 26 to gradually adjust its power output toa first power level P₁ (e.g., 5 watts) over a first time period t₁(e.g., 15 seconds). The power increase during the first time period isgenerally linear. As a result, the generator 26 increases its poweroutput at a generally constant rate of P₁/t₁. Alternatively, the powerincrease may be non-linear (e.g., exponential or parabolic) with avariable rate of increase. Once P₁ and t₁ are achieved, the algorithmmay hold at P₁ until a new time t₂ for a predetermined period of timet₂−t₁ (e.g., 3 seconds). At t₂ power is increased by a predeterminedincrement (e.g., 1 watt) to P₂ over a predetermined period of time,t₃−t₂ (e.g., 1 second). This power ramp in predetermined increments ofabout 1 watt over predetermined periods of time may continue until amaximum power P_(MAX) is achieved or some other condition is satisfied.In one embodiment, P_(MAX) is 8 watts. In another embodiment P_(MAX) is10 watts. Optionally, the power may be maintained at the maximum powerP_(MAX) for a desired period of time or up to the desired totaltreatment time (e.g., up to about 120 seconds).

In FIG. 20, the algorithm 30 illustratively includes a power-controlalgorithm. However, it should be understood that the algorithm 30alternatively may include a temperature-control algorithm. For example,power may be gradually increased until a desired temperature (ortemperatures) is obtained for a desired duration (or durations). Inanother embodiment, a combination power-control and temperature-controlalgorithm may be provided.

As discussed, the algorithm 30 includes monitoring certain operatingparameters (e.g., temperature, time, impedance, power, flow velocity,volumetric flow rate, blood pressure, heart rate, etc.). The operatingparameters may be monitored continuously or periodically. The algorithm30 checks the monitored parameters against predetermined parameterprofiles to determine whether the parameters individually or incombination fall within the ranges set by the predetermined parameterprofiles. If the monitored parameters fall within the ranges set by thepredetermined parameter profiles, then treatment may continue at thecommanded power output. If monitored parameters fall outside the rangesset by the predetermined parameter profiles, the algorithm 30 adjuststhe commanded power output accordingly. For example, if a targettemperature (e.g., 65° C.) is achieved, then power delivery is keptconstant until the total treatment time (e.g., 120 seconds) has expired.If a first temperature threshold (e.g., 70° C.) is achieved or exceeded,then power is reduced in predetermined increments (e.g., 0.5 watts, 1.0watts, etc.) until a target temperature is achieved. If a second powerthreshold (e.g., 85° C.) is achieved or exceeded, thereby indicating anundesirable condition, then power delivery may be terminated. The systemmay be equipped with various audible and visual alarms to alert theoperator of certain conditions.

The following is a non-exhaustive list of events under which algorithm30 may adjust and/or terminate/discontinue the commanded power output:

(1) The measured temperature exceeds a maximum temperature threshold(e.g., from about 70 to about 85° C.).

(2) The average temperature derived from the measured temperatureexceeds an average temperature threshold (e.g., about 65° C.).

(3) The rate of change of the measured temperature exceeds a rate ofchange threshold.

(4) The temperature rise over a period of time is below a minimumtemperature change threshold while the generator 26 has non-zero output.Poor contact between the energy delivery element(s) 24 and the arterialwall may cause such a condition.

(5) A measured impedance exceeds or falls outside an impedance threshold(e.g., <20 Ohms or >500 Ohms).

(6) A measured impedance exceeds a relative threshold (e.g., impedancedecreases from a starting or baseline value and then rises above thisbaseline value)

(7) A measured power exceeds a power threshold (e.g., >8 Watts or >10Watts).

(8) A measured duration of power delivery exceeds a time threshold(e.g., >120 seconds).

Advantageously, the magnitude of maximum power delivered during renalneuromodulation treatment in accordance with the present technology maybe relatively low (e.g., less than about 15 Watts, less than about 10Watts, less than about 8 Watts, etc.) as compared, for example, to thepower levels utilized in electrophysiology treatments to achieve cardiactissue ablation (e.g., power levels greater than about 15 Watts, greaterthan about 30 Watts, etc.). Since relatively low power levels may beutilized to achieve such renal neuromodulation, the flow rate and/ortotal volume of intravascular infusate injection needed to maintain theenergy delivery element and/or non-target tissue at or below a desiredtemperature during power delivery (e.g., at or below about 50° C., forexample, or at or below about 45° C.) also may be relatively lower thanwould be required at the higher power levels used, for example, inelectrophysiology treatments (e.g., power levels above about 15 Watts).In embodiments in which active cooling is used, the relative reductionin flow rate and/or total volume of intravascular infusate infusionadvantageously may facilitate the use of intravascular infusate inhigher risk patient groups that would be contraindicated were higherpower levels and, thus, correspondingly higher infusate rates/volumesutilized (e.g., patients with heart disease, heart failure, renalinsufficiency and/or diabetes mellitus).

C. Technical Evaluation of a Treatment

FIG. 21 is a block diagram of a treatment algorithm 2180 configured inaccordance with an embodiment of the present technology. The algorithm2180 is configured to evaluate events in a treatment, determine theprobability of technical success of the treatment and display a messageaccordingly to provide feedback to an operator of the system 10 (oranother suitable treatment system). If the treatment is determined tohave a predetermined probability of sub optimal technical success, amessage indicating that the treatment did not proceed as expected may bedisplayed. Alternative implementations can categorize a treatment intoseveral ranges of probabilities of success, such as probability ofsuccess on a scale of 1 to 5. Similarly, in certain implementations, thealgorithm 2180 can evaluate if a treatment belongs in a high probabilityof success category, a very low probability of success category, orsomewhere in between.

Variables that characterize a treatment and that may be used by thealgorithm 2180 in evaluating a treatment include, but are not limitedto: time (i.e., treatment duration), power, change in temperature,maximum temperature, mean temperature, blood flow, standard deviation oftemperature or impedance, change in impedance, or combinations of theseor other variables. For example, some or all of the variables may beprovided to the algorithm 2180 as treatment data 2182. In thisgeneralized depiction of an algorithm 2180, the treatment data 2180 maybe assessed based on a cascade or series of different categories ordegrees of criteria 2184. Favorable assessment of the treatment data2182 in view of one of the criteria 2184 may result in the display(block 2186) of a message indicating the treatment was acceptable orsuccessful. Failure of the treatment data 2182 to be found acceptable inview of a criterion 2184 may result in the treatment data dropping tothe next evaluation criterion 2184.

In the depicted embodiment, failure of the treatment data to be foundacceptable in view of all of the criteria 2184 may result in anadditional evaluation being performed, such as the depicted analysis andscoring step 2188. The output of the analysis and scoring step (e.g., ascore 2190) may be evaluated (block 2192). Based on this evaluation2192, the treatment may be deemed acceptable, and the correspondingscreen displayed (block 2186), or not acceptable, and a screen 2194displayed indicating that treatment did not proceed as expected. Instill further embodiments, the algorithm 2180 can include an automaticaction (e.g., automatic reduction of the power level supplied to theenergy source) in response to an indication that treatment did notproceed as expected.

While FIG. 21 depicts a generalized and simplified implementation of atreatment evaluation algorithm, FIG. 22 depicts a more detailed exampleof one embodiment of a treatment evaluation algorithm 2200. Thetreatment evaluation algorithm 2200 may be computed following thecompletion of a treatment (block 2202), which may be 120 seconds long(as depicted) or some other suitable duration, and using data and/ormeasurements derived over the course of the treatment.

In the depicted embodiment, it is considered likely that the greatestprobability of less than ideal treatment occurs when an electrode is notin consistent contact with the vessel wall. Accordingly, decision blocks2204, 2206, 2208, and 2210 in the flowchart are associated withdifferent criteria and screen out those treatments that appear to haveone or more criteria outside a pre-determined range (i.e., do not have ahigh probability of success) based on observed or measured data 2202over the course of the completed treatment. In the depicted embodiment,those treatments that are not screened out at decision blocks 2204,2206, 2208, and 2210 enter a linear discriminant analysis (LDA) 2212 tofurther evaluate the treatment. In other embodiments, other suitableanalyses may be performed instead of the depicted LDA. Values assignedto each step (i.e., evaluation by a respective criterion) andcoefficients 2214 used in the LDA can be derived from data collectedfrom several treatments and/or from experience gained from animalstudies.

In the depicted embodiment, the first decision block 2204 evaluates theinitial temperature response to energy delivery by checking if thechange in average temperature in the first 15 seconds is greater than14° C. In one implementation, average temperature refers to the averageover a short amount of time (e.g., 3 seconds), which essentially filterslarge fluctuations at high frequency caused by pulsatile blood flow. Aswill be appreciated, a temperature rise in the treatment electrode is aresult of heat conducting from tissue to the electrode. If an electrodeis not in sufficient contact with a vessel wall, energy is deliveredinto the blood flowing around it and the temperature of the electrode isnot increased as much. With this in mind, if the change in averagetemperature in the first 15 seconds is greater than, e.g., 14° C., thisinitial temperature response may indicate sufficient electrode contact,contact force, and/or blood flow rate, at least in the beginning of thetreatment and, if no indication that treatment did not proceed asexpected is encountered for the remainder of the treatment, there is nota high probability that the treatment was less than optimal ortechnically unsuccessful. Thus, a positive answer at decision block 2204results in a “Treatment Complete” message 2220 being displayed. However,if the change in average temperature in the first 15 seconds is lessthan or equal to, e.g., 14° C., this initial temperature response mayindicate that the electrode may not have had sufficient contact with thevessel wall. Thus, a negative answer at decision block 2204 results inproceeding to criteria 2206 for further evaluation.

At decision block 2206 the hottest temperature is evaluated by checkingif the maximum average temperature is greater than, e.g., 56° C. Atemperature rise above a threshold level (e.g., 56° C.), regardless ofduration, may be enough to allow technical success. Thus, a temperatureabove threshold may be sufficient to indicate successful lesionformation despite the fact that at decision block 2204 the initial risein temperature did not indicate sufficient contact. For example, theelectrode may not have had sufficient contact initially but then contactcould have been made at least for enough time to cause the vessel wallto heat up such that the temperature sensor in the electrode reads above56° C. A positive result at decision block 2206 results in a “TreatmentComplete” message 2220 being displayed. However, a negative result atdecision block 2206 indicates that the maximum average temperature didnot rise enough. The algorithm 2200, therefore, proceeds to decisionblock 2208 for further evaluation.

At decision block 2208 the mean temperature is evaluated during a periodwhen power is sustained at its maximum amount (i.e., the ramping upperiod is eliminated from the mean calculation). In one embodiment, thisevaluation consists of determining whether the mean real timetemperature is above 53° C. during the period from 45 seconds to 120seconds. In this manner, this criterion checks to determine iftemperature was above a threshold for a certain duration. If decisionblock 2208 yields a positive determination then, despite the fact thatthe initial temperature response and the maximum average temperaturewere insufficient to indicate technical success (i.e., decision blocks2204 and 2206 were failed), the mean temperature during the last 75seconds indicates sufficient contact for sufficient time. For example,it is possible that a sufficient lesion was made and yet the maximumaverage temperature measured in the electrode was not greater than 56°C. because there is high blood flow pulling heat from the electrode.Therefore, a positive result at decision block 2208 results in a“Treatment Complete” message 2220 being displayed. However, a negativeresult at decision block 2208 indicates that the mean real timetemperature in the sustained power stage was not sufficient and thealgorithm 2200 proceeds to decision block 2210 for further evaluation ofthe treatment.

At decision block 2210 the change in impedance is evaluated by checkingif the percentage of impedance change during a predetermined period oftime (e.g., 45 seconds to 114 seconds), is greater than a predeterminedvalue (e.g., 14%) of the initial impedance. The initial impedance isdetermined as the impedance shortly after the beginning of treatment(e.g., at 6 seconds) to eliminate possible misreadings in impedancemeasurement prior to this period (e.g., due to contrast injection). Aswill be appreciated, the impedance of tissue to radiofrequency (RF)electrical current decreases as the tissue temperature increases untilthe tissue is heated enough to cause it to desiccate at which point itsimpedance starts to rise. Therefore, a decrease in tissue impedance canindicate a rise in tissue temperature. The percentage change in realtime impedance over the sustained power stage may be calculated asfollows:

$\begin{matrix}{{\%\Delta\; Z\mspace{14mu}{over}\mspace{14mu}{SS}} = {100*\left( \frac{Z_{6s}^{avg} - \left( {{mean}\mspace{14mu}{RT}\mspace{14mu} Z\mspace{14mu}{over}\mspace{14mu}{SS}} \right)}{Z_{6s}^{avg}} \right)}} & (1)\end{matrix}$

If decision block 2210 yields a positive determination then, despite thefact that the previous three decision blocks failed to show that therewas a sufficient rise in temperature (i.e., decision blocks 2204, 2206,and 2208 were failed), the change in impedance could indicate thattissue was heated sufficiently but the temperature sensor in theelectrode did not rise enough. For example, very high blood flow couldcause the electrode temperature to remain relatively low even if thetissue was heated. Therefore, a positive result at decision block 2210results in a “Treatment Complete” message 2220 being displayed. However,a negative result at decision block 2210 results in the algorithm 2200proceeding to perform a LDA 2212.

At LDA 2212, a combination of events is evaluated along with a rating ofimportance for each event. In the depicted embodiment, for example, thecriteria evaluated at decision blocks 2204, 2206, 2208, 2210 areincluded in the LDA 2212. In addition, in this implementation, threeadditional criteria may be included: (1) standard deviation of averagetemperature (which can provide an indication of the degree of slidingmotion caused by respiration); (2) standard deviation of real timetemperature (which can provide an indication of variable blood flowand/or contact force and/or intermittent contact); and (3) adjustedchange in average impedance at the end of the treatment (which canfurther characterize change in impedance and provide an indication ofchange in temperature of tissue). If this analysis determines thecombination of variables to have a significant impact on reducingtechnical success (e.g., a LDA score<0 at decision block 2222) then an“Unexpected Treatment” message 2224 is displayed. Otherwise, a“Treatment Complete” message 2220 is displayed.

It will be appreciated that the various parameters described above aremerely representative examples associated with one embodiment of thealgorithm 2200, and one or more of these parameters may vary in otherembodiments. Further, the specific values described above with respectto particular portions of the treatment may be modified/changed in otherembodiments based on, for example, different device configurations,electrode configurations, treatment protocols, etc.

As described above, the algorithm 2200 is configured to evaluate atreatment and display a message indicating that treatment is completeor, alternatively, that treatment did not proceed as expected. Based onthe message describing the evaluation of the treatment, the clinician(or the system using automated techniques) can then decide whetherfurther treatments may be necessary and/or if one or more parametersshould be modified in subsequent treatments. In the above-describedexamples, for example, the algorithm 2200 may evaluate a number ofsituations generally related to poor contact between the electrode andvessel wall to help determine if the treatment was less than optimal.For example, poor contact may occur when an electrode slides back andforth as the patient breaths and the artery moves, when an electrodebecomes displaced when a patient moves, when the catheter is movedinadvertently, when a catheter is not deflected to the degree needed toapply sufficient contact or contact force between the electrode andvessel wall, and/or when an electrode is placed in a precariousposition. Further, as described above, if a particular parameter or setof parameters may have contributed to or resulted in a less than optimaltreatment, the system 10 (FIG. 1) can provide feedback to alert theclinician to modify one or more treatment parameters during a subsequenttreatment. Such evaluation and feedback of a treatment is expected tohelp clinicians learn to improve their placement technique to get bettercontact and reduce the frequency of technically unsuccessful treatments.

D. Feedback Related to High Temperature Conditions

While the preceding describes generalized evaluation of the technicalsuccess of a treatment, another form of feedback that may be useful toan operator of the system 10 (FIG. 1) is feedback related to specifictypes of patient or treatment conditions. For example, the system 10 maygenerate a message related to high temperature conditions. Inparticular, during a treatment while energy is being delivered, tissuetemperature may increase above a specified level. A temperature sensor(e.g., thermocouple, thermistor, etc.) positioned in or near theelectrode provides an indication of temperature in the electrode and, tosome extent, an indication of tissue temperature. The electrode does notheat directly as energy is delivered to tissue. Instead, tissue isheated and the heat conducts to the electrode and the temperature sensorin the electrode. In one implementation, the system 10 may cease energydelivery if the real time temperature rises above a predefined maximumtemperature (e.g., 85° C.). In such an event, the system may generate amessage indicating the high temperature condition. However, depending onthe circumstances, different actions by the clinician may beappropriate.

If tissue becomes too hot, established temperature thresholds can beexceeded. The implications of high tissue temperature are that an acuteconstriction of the artery or a protrusion of the artery wall couldoccur. This can happen right away or within a short time (e.g., about 50seconds to about 100 seconds) after the occurrence of the hightemperature is noted and a message is generated. In such an occurrence,the clinician may be instructed to image the treatment site to watch fora constriction or protrusion before starting another treatment.

FIG. 23, for example, is a block diagram illustrating an algorithm 2250for providing operator feedback when a high temperature condition isdetected in accordance with an embodiment of the present technology. Inone implementation the algorithm 2250 is executed in response to a hightemperature condition (block 2252) and evaluates (decision block 2254)data from the treatment to determine if the high temperature conditioninvolved a situation that included sudden instability or if it did not.Sudden instability can be caused, for example, by sudden movement of thepatient or catheter, thereby causing the electrode to be pushed harder(i.e., contact force is increased) into the vessel wall, which couldalso be accompanied by movement to another location. In the event thatsudden instability is not detected at decision block 2254, a firstmessage may be displayed (block 2256), such as an indication that a hightemperature has been detected and an instruction to image the treatmentsite to determine if the site has been damaged. In the event that suddeninstability is detected at decision block 2254, an alternative messagemay be displayed (block 2258) that, in addition to indicating theoccurrence of the high temperature and instructing the clinician toimage the treatment site, may also indicate the possibility that theelectrode may have moved from its original site. Such feedback mayprompt the clinician to compare previous images and avoid treating againon either of the original site or the site to which the electrode hasmoved.

E. Feedback Related to High Impedance

As with high temperature, in certain circumstances the system 10(FIG. 1) may generate a message related to the occurrence of highimpedance. As will be appreciated, impedance to RF current passing froma treatment electrode through the body to a dispersive return electrodecan provide an indication of characteristics of the tissue that is incontact with the treatment electrode. For example, an electrodepositioned in the blood stream in a renal artery may measure a lowerimpedance than an electrode contacting the vessel wall. Furthermore, astissue temperature rises its impedance decreases. However, if the tissuegets too hot it may desicate and its impedance may increase. During atreatment as tissue is gradually heated it is expected that impedancewill decrease. A significant rise in impedance can be a result of anundesired situation such as tissue desication or electrode movement. Incertain implementations, the system 10 may be configured to cease energydelivery if the real time impedance rise is higher than a predefinedmaximum change in impedance from the starting impedance.

FIG. 24, for example, is a block diagram illustrating an algorithm 2270for providing operator feedback upon occurrence of a high impedancecondition in accordance with an embodiment of the present technology. Inthe depicted embodiment, the algorithm 2270 evaluates data from thetreatment and determines if detection of a high impedance event (block2272) was likely to involve a situation in which (a) tissue temperaturewas high and desiccation was likely, (b) the electrode moved, or (c)there was poor electrode contact or no electrode contact with the vesselwall. The algorithm 170 evaluates the data to determine which, if any,of these three situations occurred and displays one of three messages2274, 2276, or 2278 accordingly.

In accordance with one embodiment of the algorithm 2270, upon detectionof a high impedance (block 2272), the maximum average temperature duringthe treatment is evaluated (decision block 2280). If this temperature isabove a certain threshold (e.g., at or above 60° C.) then the highimpedance may be attributed to high tissue temperature resulting indesiccation. In this event, message 2274 may be displayed instructingthe clinician to check for a constriction or protrusion (i.e., to imagethe treatment site) and to avoid treating again in the same location.Conversely, if the temperature is below the threshold (e.g., below 60°C.), the algorithm 2270 proceeds to decision block 2282.

In the depicted embodiment, at decision block 2282, the algorithm 2270evaluates if the high impedance event occurred early in treatment (e.g.,in the first 20 seconds of energy delivery) when power is relativelylow. If yes, it is unlikely that tissue temperature was high and morelikely that the electrode initially had poor or no contact andsubsequently established better contact, causing impedance to jump. Inthis event message 2276 may be displayed instructing the clinician toattempt to establish better contact and repeat treatment at the samesite. However, if the event occurs later in treatment (e.g., more than20 seconds elapsed), the algorithm 2270 proceeds to decision block 2284.

At decision block 2284, the algorithm 2270 evaluates when the highimpedance event occurred during treatment. For example, if the eventoccurred after a predetermined period of time (e.g., 45 seconds), whenthe power has reached high levels, the algorithm proceeds to decisionblock 2286. However, if the event occurred when power is being ramped upand is not at its highest (e.g., between 20 seconds and 45 seconds), thealgorithm proceeds to decision block 2288.

At decision block 2286, the algorithm 2270 calculates the percentagechange in impedance (% ΔZ) at the time of the high impedance eventcompared to the impedance at a specified time (e.g., 45 seconds). Thisis the period when power is sustained at a high level. In oneembodiment, the percentage change in impedance is calculated as:

$\begin{matrix}{{\%\Delta Z} = {100*{\frac{\left\lbrack {\left( {{final}\mspace{20mu}{avgZ}} \right) - \left( {{{avgZ}@45}\mspace{14mu}\sec} \right)} \right\rbrack}{\left( {avg{Z@4}5\mspace{14mu}\sec} \right)}}}} & (2)\end{matrix}$

If % ΔZ is greater than or equal to a predetermined amount (e.g., 7%)then it may be likely that tissue began to desiccate due to hightemperature. In this event, message 2274 may be displayed instructingthe clinician to check for a constriction or protrusion (i.e., to imagethe treatment site) and to avoid treating again in the same location.Otherwise, tissue desiccation is less likely and it is more likely thatthe electrode moved to cause the high impedance event. In this event,message 2278 may be displayed notifying the clinician that the electrodemay have moved. In the event the electrode has moved or may have moved,it is unlikely that tissue temperature reached a high level.Accordingly, it is expected that treating in the same location can bedone if there are no or limited other locations to perform anothertreatment.

At decision block 2288, the algorithm 2270 may determine whether asudden instability occurred. If such instability was present, it islikely that the electrode moved. In this event, message 2278 may bedisplayed notifying the clinician that the electrode may have moved. Asdiscussed above, the clinician may exhibit caution and avoid treatingthe original location or the location to which the electrode moved orthe clinician may opt to treat in the same location if no other sites ora limited number of sites are available for further treatment.Otherwise, if no sudden instability occurred, it is more likely that theelectrode had poor contact. In this event, message 2276 may be displayedinstructing the clinician to attempt to establish better contact andthat treating the same site is safe.

The same objective of detecting high impedance conditions can beachieved using alternate measurements and calculations. For example, ina further embodiment of the algorithm 2270, temperature and impedancedata is taken for a sample time interval (e.g., 20 seconds). At ashorter time interval (e.g., every 1.5 seconds), the standard deviationof the impedance and temperature data is calculated. A first standardtemperature for an interval is calculated as the standard deviation ofthe temperature divided by the standard deviation of the temperature atthe initial time interval. If the standard deviation of the impedancemeasurements is greater than or equal to a pre-determined value (e.g.,10 Ohms), and the first standard temperature is greater than apre-determined threshold (e.g., 3), then the algorithm 2270 can displaymessage 2276, indicating poor electrode contact. However, if thestandard deviation of the impedance measurement is outside theacceptable range, but the first standard temperature is within theacceptable range, then message 2278 will be displayed to alert theclinician that there is electrode instability.

In accordance with a further embodiment of the algorithm 2270, theimpedance of two or more electrodes 24 (e.g., positioned on thetreatment region 22 of the catheter 12 of FIG. 1) can each provide anindependent impedance reading. During delivery of the therapeuticassembly 22 to the treatment site (e.g., within the renal artery), theimpedance readings of the electrodes 24 are typically different due tothe anatomy of the vasculature, as the catheter 12 will conform to thepath of least resistance, often bending at vasculature curves to onlycontact one wall of the renal artery. In some embodiments, once thetherapeutic assembly 22 is in position for treatment, the therapeuticassembly 22 can be expanded circumferentially to contact the entirecircumferential surface of a segment of the renal artery wall. Thisexpansion can place multiple electrodes 24 in contact with the renalartery wall. As the therapeutic assembly 22 is expanded into thetreatment configuration and the electrodes 24 make increased contactwith the renal artery wall, the impedance values of the individualelectrodes 24 can increase and/or approach the same value. With good,stable contact, fluctuations of impedance values also reduce asdescribed above. The energy generator 26 can continually or continuouslymonitor the individual impedance values. The values can then be comparedto determine when contact has been effectively made, as an indication ofsuccessful treatment. In further embodiments, a moving average ofimpedance can be compared to a pre-determined range of variability ofimpedance values with limits set to guide stability measures.

F. Feedback Related to Vasoconstriction

In further embodiments, the system 10 may generate a message related tothe occurrence of vasoconstriction. In particular, while treatment isbeing delivered, blood vessels may contract to a less-than-optimaldiameter. Constricted blood vessels can lead to reduced blood flow,increased treatment site temperatures, and increased blood pressure.Vasoconstriction can be measured by sampling the amplitude (the“envelope”) of real-time temperature data. The current envelope can becompared to a previous envelope sample taken (e.g., 200 ms prior). Ifthe difference between the current envelope and the previous time pointenvelope is less than a pre-determined value (e.g., less than −0.5° C.,or, in other words, there is a less than a 0.5 degree reduction in thepresent envelope value compared to the envelope value at the previoustime point), then measurements are taken at a future time point (e.g.,in 5 seconds). If the difference in average temperature at the futuretime point and the current time point is more than a given temperaturethreshold (e.g., more than 1° C.), then an algorithm 2500 may determinethat an undesirably high level of constriction exists, and cancease/alter energy delivery. In such an event, the system 10 maygenerate a message indicating the high constriction condition. However,depending on the circumstances, different actions by the clinician maybe appropriate.

FIG. 25, for example, is a block diagram illustrating an algorithm 2500for providing operator feedback when a high degree of vesselconstriction is detected in accordance with an embodiment of the presenttechnology. In one implementation, the algorithm 2500 is executed inresponse to a high constriction level (e.g., vessels constricted at orbelow a certain diameter) (Block 2502) and evaluates (decision block2504) data from the treatment to determine if the high constrictionlevel involved a situation that included sudden instability or if it didnot. An indication of sudden instability can indicate that the electrode24 moved.

In the event that sudden instability is not detected at decision block2504, a first message may be displayed (block 2506), such as anindication that a high constriction level has been detected and aninstruction to a clinician to reduce treatment power. In furtherembodiments, the energy level may be automatically altered in responseto the detected constriction level. In the event that sudden instabilityis detected at decision block 2504, an alternative message may bedisplayed (block 2508) that, in addition to indicating the occurrence ofthe high constriction level and instructions to the clinician, may alsoindicate the possibility that the electrode 24 may have moved from itsoriginal site. Such feedback may prompt the clinician to alter or ceasetreatment.

G. Feedback Related to Cardiac Factors

1. Feedback Related to Abnormal Heart Rate

Like other physiological conditions mentioned above, in certaincircumstances the system 10 may generate a message related to theoccurrence of an abnormal heart rate. In particular, while treatment isbeing delivered, heart rate may exceed or fall below desirableconditions (e.g., temporary procedural or chronic bradycardia).Instantaneous heart rate can be determined by measuring real-timetemperature and impedance. More specifically, a real-time temperaturereading can be filtered, for example, between 0.5 Hz and 2.5 Hz using asecond order Butterworth filter. Local maxima of the filtered signal aredetermined. The local maxima are the detected peaks of thereal-temperature signal. The instantaneous beat rate is the intervalbetween the peaks, as the signal peaks correspond to the periodic changein the cardiac cycle.

In one implementation, the system 10 may cease/alter energy delivery ifthe heart rate falls outside a desirable range. In such an event, thesystem may generate a message indicating the adverse heart ratecondition. However, depending on the circumstances, different actions bythe clinician may be appropriate.

FIG. 26A, for example, is a block diagram illustrating an algorithm 2600for providing operator feedback/instructions upon detection of anabnormal heart rate condition in accordance with an embodiment of thepresent technology. In one implementation, for example, the algorithm2600 may be executed in response to an abnormal heart rate condition(e.g., above or below a pre-determined threshold) (Block 2602). Atdecision block 2604, the algorithm 2600 evaluates data from thetreatment to determine if the detected abnormal heart rate conditioninvolved a situation that included sudden instability. An indication ofsudden instability can indicate that the electrode moved.

In the event that sudden instability is not detected at decision block2604, a first message may be displayed to the clinician (block 2606),such as an indication that an abnormal heart rate has been detected andan instruction to the clinician to reduce treatment power. In furtherembodiments, the energy level may be automatically altered in responseto the detected adverse heart rate. In the event that sudden instabilityis detected at decision block 2604, an alternative message may bedisplayed (block 2608) that, in addition to indicating the occurrence ofthe abnormal heart rate and instructions to the clinician, may alsoindicate the possibility that the electrode may have moved from itsoriginal site. Such feedback may prompt the clinician to alter or ceasetreatment.

2. Feedback Related to Low Blood Flow

The system 10 may also be configured to generate a message related tolow blood flow conditions. For example, if blood flow falls below acertain level during treatment (or if vessels are undesirably narrow),the convective heat removed from the electrode 24 and tissue surface isreduced. Excessively high tissue temperatures can lead to the negativeoutcomes described above, such as thrombosis, charring, unreliablelesion size, etc. Reducing power from the generator 26 to prevent thetissue from reaching an unacceptable temperature can lead toinsufficient lesion depth, and nerves may not be heated to sufficientablation temperatures. An algorithm can be used to measure blood flow orthe loss of heat to the blood stream. In one embodiment, blood flow canbe measured with a flow meter or a Doppler sensor placed in the renalartery on a separate catheter or on the treatment catheter 12. Inanother embodiment, heat loss or thermal decay can be measured bydelivering energy (e.g., RF energy) to raise a blood, tissue, orsubstrate temperature. The energy can be turned off and the algorithmcan include monitoring the temperature as a gauge of thermal decay. Arapid thermal decay may represent sufficient blood flow, while a gradualthermal decay may represent low blood flow. For example, in oneembodiment, the algorithm 2610 can indicate a low blood flow if theslope of real-time temperature measurements over the startingtemperature exceeds a preset threshold (e.g., 2.75) and the averagetemperature is greater than a preset temperature (e.g., 65° C.). Infurther embodiments, thermal decay and/or blood flow can becharacterized by measuring temperature oscillations of an electrodedelivering RF or resistive heat. At a given temperature or powerdelivery amplitude/magnitude, a narrow oscillation range may indicate arelatively low thermal decay/blood flow.

FIG. 26B, for example, is a block diagram illustrating an algorithm 2610for providing operator feedback/instructions upon occurrence of a lowblood flow condition in accordance with an embodiment of the presenttechnology. In one implementation, the algorithm 2610 is executed inresponse to a detected low blood flow condition (e.g., flow below apre-determined threshold) (Block 2612). At block 2614, the algorithm2610 evaluates data from the treatment to determine if the low bloodflow condition involved a situation that included sudden instability. Inthe event that sudden instability is not detected at decision block2614, a first message may be displayed (block 2616), such as anindication that low blood flow has been detected and an instruction to aclinician to reduce treatment power. In the event that suddeninstability is detected, an alternative message may be displayed (block2618) that, in addition to indicating the occurrence of low blood flowand instructions to the clinician, may also indicate the possibilitythat the electrode may have moved from its original site. As notedabove, such feedback may prompt the clinician to alter or ceasetreatment.

In further embodiments, if blood flow or thermal decay values are lowerthan a typical or pre-determined threshold, the energy deliveryalgorithm 2610 can include automatically altering one or more conditionsor characteristics of treatment or of the catheter to improve bloodflow. For example, in one embodiment, the algorithm 2610 can respond toa low blood flow by pulsing the energy provided to the energy deliveryelement 264 rather than providing continuous energy. This may allow thelower blood flow to more adequately remove heat from the tissue surfacewhile still creating a sufficiently deep lesion to ablate a nerve.

In another embodiment, the algorithm 2610 can include responding to alow blood flow by cooling the electrodes, as described in further detailin International Patent Application No. PCT/US2011/033491, filed Apr.26, 2011, and U.S. patent application Ser. No. 12/874,457, filed Aug.30, 2010. The foregoing applications are incorporated herein byreference in their entireties.

In a further embodiment, the algorithm 2610 can respond to a low bloodflow by requiring a manual increase of blood flow to the region. Forexample, a non-occlusive balloon can be inflated in the abdominal aorta,thereby increasing pressure and flow in the renal artery. The ballooncan be incorporated on the treatment catheter or on a separate catheter.

H. Feedback Display

FIGS. 27A and 27B are screen shots illustrating representative generatordisplay screens configured in accordance with aspects of the presenttechnology. FIG. 27A, for example, is a display screen 2700 for enhancedimpedance tracking during treatment. The display 2700 includes agraphical display 2710 that tracks impedance measurements in real timeover a selected period of time (e.g., 100 seconds). This graphicaldisplay 2710, for example, can be a dynamic, rolling display that isupdated at periodic intervals to provide an operator with bothinstantaneous and historical tracking of impedance measurements. Thedisplay 2710 can also includes an impedance display 2720 with thecurrent impedance as well as a standard deviation indication 2722 forthe impedance. In one embodiment, the standard deviation indication 2722is configured to flash when this value is greater than 10. Such anindication can alert the operator of a contrast injection that isaffecting the measurement or that the electrode may be unstable. Furtherinformation about contrast injection indications are described below.

FIG. 27B, for example, is another representative display screen 2730with additional information for an operator. In this example, thedisplay screen 2730 is configured to alert the operator of a contrastinjection and that the system is waiting for contrast to clear beforecommencing (e.g., disable RF for approximately 1 to 2 seconds untilcontrast clears). In another embodiment, the display screen 2730 may beconfigured to provide other alert messages (e.g., “POSSIBLE UNSTABLEELECTRODE,” etc.). The additional information provided in the displayscreens 2710 and 2730 described above is expected to improve contactassessment prior to RF ON, and improve treatment efficiency andefficacy.

The additional information described above with reference to FIGS. 27Aand 10B can be generated based on the algorithms described herein, orother suitable algorithms. In one embodiment, for example, an algorithmcan continuously check for contrast injection/stability during pre-RFON. If the electrode is stable and there is no contrast for ≥1 second,the baseline impedance Z is set equal to the average impedance Z over 1second. In one particular example, the real time impedance is comparedwith two standard deviations of the mean impedance value within a onesecond window. In another specific example, the real time impedance maybe compared with a fixed number (e.g., determine if the standarddeviation is greater than 10). In still other examples, otherarrangements may be used.

If the real time impedance measurement is within this range, no messageis displayed. However, if the real time impedance is not within twostandard deviations of the mean, the electrode may not stable (i.e.,drifting, moving, etc.) and one or both of the message(s) describedabove with reference to FIGS. 27A and 27B may be displayed to the user(e.g., “WAITING FOR CONTRAST TO CLEAR,” “POSSIBLE UNSTABLE ELECTRODE”).By way of example, for contrast injection detection, in addition to thestandard deviation of the impedance, the algorithm may be configured tofactor in the standard deviation of a real time temperature measurementto look for excursions of the real time temperature below a startingbody temperature. The exact value for the temperature excursion cut offcan vary. In one particular example, the system is configured such thatif there is an increase in impedance (e.g., standard deviation>10)accompanied by a drop in real time temperature, the system will flag aContrast Detected event leading to the “WAITING FOR CONTRAST TO CLEAR”message to be displayed to the operator. In other examples, however,other algorithms and/or ranges may be used to determine contrastinjection events and/or the stability of the electrode. Further, in someembodiments the system may modify/adjust various treatment parametersbased on detected conditions without displaying such messages to theclinician.

VII. Prepackaged Kit for Distribution, Transport and Sale of theDisclosed Apparatuses and Systems

As shown in FIG. 28, one or more components of the system 10 shown inFIG. 1 may be packaged together in a kit 276 for convenient delivery toand use by the customer/clinical operator. Components suitable forpackaging include, the treatment device 12, the cable 28 for connectingthe treatment device 12 to the energy generator 26, the neutral ordispersive electrode 38, and one or more guide catheters (e.g., a renalguide catheter). Cable 28 may also be integrated into the treatmentdevice 12 such that both components are packaged together. Eachcomponent may have its own sterile packaging (for components requiringsterilization) or the components may have dedicated sterilizedcompartments within the kit packaging. This kit may also includestep-by-step instructions 280 for use that provide the operator withtechnical product features and operating instructions for using thesystem 10 and treatment device 12, including all methods of insertion,delivery, placement, and use of the treatment device 12 disclosedherein.

VIII. Additional Clinical Uses of the Disclosed Technology

Although certain embodiments of the present techniques relate to atleast partially denervating a kidney of a patient to block afferentand/or efferent neural communication from within a renal blood vessel(e.g., renal artery), the apparatuses, methods and systems describedherein may also be used for other intravascular treatments. For example,the aforementioned catheter system, or select aspects of such system,may be placed in other peripheral blood vessels to deliver energy and/orelectric fields to achieve a neuromodulatory affect by altering nervesproximate to these other peripheral blood vessels. There are a number ofarterial vessels arising from the aorta which travel alongside a richcollection of nerves to target organs. Utilizing the arteries to accessand modulate these nerves may have clear therapeutic potential in anumber of disease states. Some examples include the nerves encirclingthe celiac trunk, superior mesenteric artery, and inferior mesentericartery.

Sympathetic nerves proximate to or encircling the arterial blood vesselknown as the celiac trunk may pass through the celiac ganglion andfollow branches of the celiac trunk to innervate the stomach, smallintestine, abdominal blood vessels, liver, bile ducts, gallbladder,pancreas, adrenal glands, and kidneys. Modulating these nerves in whole(or in part via selective modulation) may enable treatment of conditionsincluding, but not limited to, diabetes, pancreatitis, obesity,hypertension, obesity related hypertension, hepatitis, hepatorenalsyndrome, gastric ulcers, gastric motility disorders, irritable bowelsyndrome, and autoimmune disorders such as Crohn's disease.

Sympathetic nerves proximate to or encircling the arterial blood vesselknown as the inferior mesenteric artery may pass through the inferiormesenteric ganglion and follow branches of the inferior mesentericartery to innervate the colon, rectum, bladder, sex organs, and externalgenitalia. Modulating these nerves in whole (or in part via selectivemodulation) may enable treatment of conditions including, but notlimited to, GI motility disorders, colitis, urinary retention,hyperactive bladder, incontinence, infertility, polycystic ovariansyndrome, premature ejaculation, erectile dysfunction, dyspareunia, andvaginismus.

While arterial access and treatments received have been provided herein,the disclosed apparatuses, methods and systems may also be used todeliver treatment from within a peripheral vein or lymphatic vessel.

IX. Additional Discussion of Pertinent Anatomy and Physiology

The following discussion provides further details regarding pertinentpatient anatomy and physiology. This section is intended to supplementand expand upon the previous discussion regarding the relevant anatomyand physiology, and to provide additional context regarding thedisclosed technology and the therapeutic benefits associated with renaldenervation. For example, as mentioned previously, several properties ofthe renal vasculature may inform the design of treatment devices andassociated methods for achieving renal neuromodulation via intravascularaccess, and impose specific design requirements for such devices.Specific design requirements may include accessing the renal artery,facilitating stable contact between the energy delivery elements of suchdevices and a luminal surface or wall of the renal artery, and/oreffectively modulating the renal nerves with the neuromodulatoryapparatus.

A. The Sympathetic Nervous System

The Sympathetic Nervous System (SNS) is a branch of the autonomicnervous system along with the enteric nervous system and parasympatheticnervous system. It is always active at a basal level (called sympathetictone) and becomes more active during times of stress. Like other partsof the nervous system, the sympathetic nervous system operates through aseries of interconnected neurons. Sympathetic neurons are frequentlyconsidered part of the peripheral nervous system (PNS), although manylie within the central nervous system (CNS). Sympathetic neurons of thespinal cord (which is part of the CNS) communicate with peripheralsympathetic neurons via a series of sympathetic ganglia. Within theganglia, spinal cord sympathetic neurons join peripheral sympatheticneurons through synapses. Spinal cord sympathetic neurons are thereforecalled presynaptic (or preganglionic) neurons, while peripheralsympathetic neurons are called postsynaptic (or postganglionic) neurons.

At synapses within the sympathetic ganglia, preganglionic sympatheticneurons release acetylcholine, a chemical messenger that binds andactivates nicotinic acetylcholine receptors on postganglionic neurons.In response to this stimulus, postganglionic neurons principally releasenoradrenaline (norepinephrine). Prolonged activation may elicit therelease of adrenaline from the adrenal medulla.

Once released, norepinephrine and epinephrine bind adrenergic receptorson peripheral tissues. Binding to adrenergic receptors causes a neuronaland hormonal response. The physiologic manifestations include pupildilation, increased heart rate, occasional vomiting, and increased bloodpressure. Increased sweating is also seen due to binding of cholinergicreceptors of the sweat glands.

The sympathetic nervous system is responsible for up- anddown-regulating many homeostatic mechanisms in living organisms. Fibersfrom the SNS innervate tissues in almost every organ system, providingat least some regulatory function to things as diverse as pupildiameter, gut motility, and urinary output. This response is also knownas sympatho-adrenal response of the body, as the preganglionicsympathetic fibers that end in the adrenal medulla (but also all othersympathetic fibers) secrete acetylcholine, which activates the secretionof adrenaline (epinephrine) and to a lesser extent noradrenaline(norepinephrine). Therefore, this response that acts primarily on thecardiovascular system is mediated directly via impulses transmittedthrough the sympathetic nervous system and indirectly via catecholaminessecreted from the adrenal medulla.

Science typically looks at the SNS as an automatic regulation system,that is, one that operates without the intervention of consciousthought. Some evolutionary theorists suggest that the sympatheticnervous system operated in early organisms to maintain survival as thesympathetic nervous system is responsible for priming the body foraction. One example of this priming is in the moments before waking, inwhich sympathetic outflow spontaneously increases in preparation foraction.

1. The Sympathetic Chain

As shown in FIG. 29, the SNS provides a network of nerves that allowsthe brain to communicate with the body. Sympathetic nerves originateinside the vertebral column, toward the middle of the spinal cord in theintermediolateral cell column (or lateral horn), beginning at the firstthoracic segment of the spinal cord and are thought to extend to thesecond or third lumbar segments. Because its cells begin in the thoracicand lumbar regions of the spinal cord, the SNS is said to have athoracolumbar outflow. Axons of these nerves leave the spinal cordthrough the anterior rootlet/root. They pass near the spinal (sensory)ganglion, where they enter the anterior rami of the spinal nerves.However, unlike somatic innervation, they quickly separate out throughwhite rami connectors which connect to either the paravertebral (whichlie near the vertebral column) or prevertebral (which lie near theaortic bifurcation) ganglia extending alongside the spinal column.

In order to reach the target organs and glands, the axons should travellong distances in the body, and, to accomplish this, many axons relaytheir message to a second cell through synaptic transmission. The endsof the axons link across a space, the synapse, to the dendrites of thesecond cell. The first cell (the presynaptic cell) sends aneurotransmitter across the synaptic cleft where it activates the secondcell (the postsynaptic cell). The message is then carried to the finaldestination.

In the SNS and other components of the peripheral nervous system, thesesynapses are made at sites called ganglia. The cell that sends its fiberis called a preganglionic cell, while the cell whose fiber leaves theganglion is called a postganglionic cell. As mentioned previously, thepreganglionic cells of the SNS are located between the first thoracic(T1) segment and third lumbar (L3) segments of the spinal cord.Postganglionic cells have their cell bodies in the ganglia and sendtheir axons to target organs or glands.

The ganglia include not just the sympathetic trunks but also thecervical ganglia (superior, middle and inferior), which sendssympathetic nerve fibers to the head and thorax organs, and the celiacand mesenteric ganglia (which send sympathetic fibers to the gut).

2. Innervation of the Kidneys

As FIG. 30 shows, the kidney is innervated by the renal plexus RP, whichis intimately associated with the renal artery. The renal plexus RP isan autonomic plexus that surrounds the renal artery and is embeddedwithin the adventitia of the renal artery. The renal plexus RP extendsalong the renal artery until it arrives at the substance of the kidney.Fibers contributing to the renal plexus RP arise from the celiacganglion, the superior mesenteric ganglion, the aorticorenal ganglionand the aortic plexus. The renal plexus RP, also referred to as therenal nerve, is predominantly comprised of sympathetic components. Thereis no (or at least very minimal) parasympathetic innervation of thekidney.

Preganglionic neuronal cell bodies are located in the intermediolateralcell column of the spinal cord. Preganglionic axons pass through theparavertebral ganglia (they do not synapse) to become the lessersplanchnic nerve, the least splanchnic nerve, first lumbar splanchnicnerve, second lumbar splanchnic nerve, and travel to the celiacganglion, the superior mesenteric ganglion, and the aorticorenalganglion. Postganglionic neuronal cell bodies exit the celiac ganglion,the superior mesenteric ganglion, and the aorticorenal ganglion to therenal plexus RP and are distributed to the renal vasculature.

3. Renal Sympathetic Neural Activity

Messages travel through the SNS in a bidirectional flow. Efferentmessages may trigger changes in different parts of the bodysimultaneously. For example, the sympathetic nervous system mayaccelerate heart rate; widen bronchial passages; decrease motility(movement) of the large intestine; constrict blood vessels; increaseperistalsis in the esophagus; cause pupil dilation, piloerection (goosebumps) and perspiration (sweating); and raise blood pressure. Afferentmessages carry signals from various organs and sensory receptors in thebody to other organs and, particularly, the brain.

Hypertension, heart failure and chronic kidney disease are a few of manydisease states that result from chronic activation of the SNS,especially the renal sympathetic nervous system. Chronic activation ofthe SNS is a maladaptive response that drives the progression of thesedisease states. Pharmaceutical management of therenin-angiotensin-aldosterone system (RAAS) has been a longstanding, butsomewhat ineffective, approach for reducing over-activity of the SNS.

As mentioned above, the renal sympathetic nervous system has beenidentified as a major contributor to the complex pathophysiology ofhypertension, states of volume overload (such as heart failure), andprogressive renal disease, both experimentally and in humans. Studiesemploying radiotracer dilution methodology to measure overflow ofnorepinephrine from the kidneys to plasma revealed increased renalnorepinephrine (NE) spillover rates in patients with essentialhypertension, particularly so in young hypertensive subjects, which inconcert with increased NE spillover from the heart, is consistent withthe hemodynamic profile typically seen in early hypertension andcharacterized by an increased heart rate, cardiac output, andrenovascular resistance. It is now known that essential hypertension iscommonly neurogenic, often accompanied by pronounced sympathetic nervoussystem overactivity.

Activation of cardiorenal sympathetic nerve activity is even morepronounced in heart failure, as demonstrated by an exaggerated increaseof NE overflow from the heart and the kidneys to plasma in this patientgroup. In line with this notion is the recent demonstration of a strongnegative predictive value of renal sympathetic activation on all-causemortality and heart transplantation in patients with congestive heartfailure, which is independent of overall sympathetic activity,glomerular filtration rate, and left ventricular ejection fraction.These findings support the notion that treatment regimens that aredesigned to reduce renal sympathetic stimulation have the potential toimprove survival in patients with heart failure.

Both chronic and end stage renal disease are characterized by heightenedsympathetic nervous activation. In patients with end stage renaldisease, plasma levels of norepinephrine above the median have beendemonstrated to be predictive for both all-cause death and death fromcardiovascular disease. This is also true for patients suffering fromdiabetic or contrast nephropathy. There is compelling evidencesuggesting that sensory afferent signals originating from the diseasedkidneys are major contributors to initiating and sustaining elevatedcentral sympathetic outflow in this patient group; this facilitates theoccurrence of the well known adverse consequences of chronic sympatheticover activity, such as hypertension, left ventricular hypertrophy,ventricular arrhythmias, sudden cardiac death, insulin resistance,diabetes, and metabolic syndrome.

(i) Renal Sympathetic Efferent Activity

Sympathetic nerves to the kidneys terminate in the blood vessels, thejuxtaglomerular apparatus and the renal tubules. Stimulation of therenal sympathetic nerves causes increased renin release, increasedsodium (Na+) reabsorption, and a reduction of renal blood flow. Thesecomponents of the neural regulation of renal function are considerablystimulated in disease states characterized by heightened sympathetictone and clearly contribute to the rise in blood pressure inhypertensive patients. The reduction of renal blood flow and glomerularfiltration rate as a result of renal sympathetic efferent stimulation islikely a cornerstone of the loss of renal function in cardio-renalsyndrome, which is renal dysfunction as a progressive complication ofchronic heart failure, with a clinical course that typically fluctuateswith the patient's clinical status and treatment. Pharmacologicstrategies to thwart the consequences of renal efferent sympatheticstimulation include centrally acting sympatholytic drugs, beta blockers(intended to reduce renin release), angiotensin converting enzymeinhibitors and receptor blockers (intended to block the action ofangiotensin II and aldosterone activation consequent to renin release)and diuretics (intended to counter the renal sympathetic mediated sodiumand water retention). However, the current pharmacologic strategies havesignificant limitations including limited efficacy, compliance issues,side effects and others.

(ii) Renal Sensory Afferent Nerve Activity

The kidneys communicate with integral structures in the central nervoussystem via renal sensory afferent nerves. Several forms of “renalinjury” may induce activation of sensory afferent signals. For example,renal ischemia, reduction in stroke volume or renal blood flow, or anabundance of adenosine enzyme may trigger activation of afferent neuralcommunication. As shown in FIGS. 31A and 31B, this afferentcommunication might be from the kidney to the brain or might be from onekidney to the other kidney (via the central nervous system). Theseafferent signals are centrally integrated and may result in increasedsympathetic outflow. This sympathetic drive is directed towards thekidneys, thereby activating the RAAS and inducing increased reninsecretion, sodium retention, volume retention and vasoconstriction.Central sympathetic over activity also impacts other organs and bodilystructures innervated by sympathetic nerves such as the heart and theperipheral vasculature, resulting in the described adverse effects ofsympathetic activation, several aspects of which also contribute to therise in blood pressure.

The physiology therefore suggests that (i) modulation of tissue withefferent sympathetic nerves will reduce inappropriate renin release,salt retention, and reduction of renal blood flow, and that (ii)modulation of tissue with afferent sensory nerves will reduce thesystemic contribution to hypertension and other disease statesassociated with increased central sympathetic tone through its directeffect on the posterior hypothalamus as well as the contralateralkidney. In addition to the central hypotensive effects of afferent renaldenervation, a desirable reduction of central sympathetic outflow tovarious other sympathetically innervated organs such as the heart andthe vasculature is anticipated.

B. Additional Clinical Benefits of Renal Denervation

As provided above, renal denervation is likely to be valuable in thetreatment of several clinical conditions characterized by increasedoverall and particularly renal sympathetic activity such ashypertension, metabolic syndrome, insulin resistance, diabetes, leftventricular hypertrophy, chronic end stage renal disease, inappropriatefluid retention in heart failure, cardio-renal syndrome, and suddendeath. Since the reduction of afferent neural signals contributes to thesystemic reduction of sympathetic tone/drive, renal denervation mightalso be useful in treating other conditions associated with systemicsympathetic hyperactivity. Accordingly, renal denervation may alsobenefit other organs and bodily structures innervated by sympatheticnerves, including those identified in FIG. 29. For example, aspreviously discussed, a reduction in central sympathetic drive mayreduce the insulin resistance that afflicts people with metabolicsyndrome and Type II diabetics. Additionally, patients with osteoporosisare also sympathetically activated and might also benefit from the downregulation of sympathetic drive that accompanies renal denervation.

C. Achieving Intravascular Access to the Renal Artery

In accordance with the present technology, neuromodulation of a leftand/or right renal plexus RP, which is intimately associated with a leftand/or right renal artery, may be achieved through intravascular access.As FIG. 32A shows, blood moved by contractions of the heart is conveyedfrom the left ventricle of the heart by the aorta. The aorta descendsthrough the thorax and branches into the left and right renal arteries.Below the renal arteries, the aorta bifurcates at the left and rightiliac arteries. The left and right iliac arteries descend, respectively,through the left and right legs and join the left and right femoralarteries.

As FIG. 32B shows, the blood collects in veins and returns to the heart,through the femoral veins into the iliac veins and into the inferiorvena cava. The inferior vena cava branches into the left and right renalveins. Above the renal veins, the inferior vena cava ascends to conveyblood into the right atrium of the heart. From the right atrium, theblood is pumped through the right ventricle into the lungs, where it isoxygenated. From the lungs, the oxygenated blood is conveyed into theleft atrium. From the left atrium, the oxygenated blood is conveyed bythe left ventricle back to the aorta.

As will be described in greater detail later, the femoral artery may beaccessed and cannulated at the base of the femoral triangle justinferior to the midpoint of the inguinal ligament. A catheter may beinserted percutaneously into the femoral artery through this accesssite, passed through the iliac artery and aorta, and placed into eitherthe left or right renal artery. This comprises an intravascular paththat offers minimally invasive access to a respective renal arteryand/or other renal blood vessels.

The wrist, upper arm, and shoulder region provide other locations forintroduction of catheters into the arterial system. For example,catheterization of either the radial, brachial, or axillary artery maybe utilized in select cases. Catheters introduced via these accesspoints may be passed through the subclavian artery on the left side (orvia the subclavian and brachiocephalic arteries on the right side),through the aortic arch, down the descending aorta and into the renalarteries using standard angiographic technique.

D. Properties and Characteristics of the Renal Vasculature

Since neuromodulation of a left and/or right renal plexus RP may beachieved in accordance with the present technology through intravascularaccess, properties and characteristics of the renal vasculature mayimpose constraints upon and/or inform the design of apparatus, systems,and methods for achieving such renal neuromodulation. Some of theseproperties and characteristics may vary across the patient populationand/or within a specific patient across time, as well as in response todisease states, such as hypertension, chronic kidney disease, vasculardisease, end-stage renal disease, insulin resistance, diabetes,metabolic syndrome, etc. These properties and characteristics, asexplained herein, may have bearing on the efficacy of the procedure andthe specific design of the intravascular device. Properties of interestmay include, for example, material/mechanical, spatial, fluiddynamic/hemodynamic and/or thermodynamic properties.

As discussed previously, a catheter may be advanced percutaneously intoeither the left or right renal artery via a minimally invasiveintravascular path. However, minimally invasive renal arterial accessmay be challenging, for example, because as compared to some otherarteries that are routinely accessed using catheters, the renal arteriesare often extremely tortuous, may be of relatively small diameter,and/or may be of relatively short length. Furthermore, renal arterialatherosclerosis is common in many patients, particularly those withcardiovascular disease. Renal arterial anatomy also may varysignificantly from patient to patient, which further complicatesminimally invasive access. Significant inter-patient variation may beseen, for example, in relative tortuosity, diameter, length, and/oratherosclerotic plaque burden, as well as in the take-off angle at whicha renal artery branches from the aorta. Apparatus, systems and methodsfor achieving renal neuromodulation via intravascular access shouldaccount for these and other aspects of renal arterial anatomy and itsvariation across the patient population when minimally invasivelyaccessing a renal artery.

In addition to complicating renal arterial access, specifics of therenal anatomy also complicate establishment of stable contact betweenneuromodulatory apparatus and a luminal surface or wall of a renalartery. When the neuromodulatory apparatus includes an energy deliveryelement, such as an electrode, consistent positioning and appropriatecontact force applied by the energy delivery element to the vessel wallare important for predictability. However, navigation is impeded by thetight space within a renal artery, as well as tortuosity of the artery.Furthermore, establishing consistent contact is complicated by patientmovement, respiration, and/or the cardiac cycle because these factorsmay cause significant movement of the renal artery relative to theaorta, and the cardiac cycle may transiently distend the renal artery(i.e., cause the wall of the artery to pulse.

Even after accessing a renal artery and facilitating stable contactbetween neuromodulatory apparatus and a luminal surface of the artery,nerves in and around the adventia of the artery should be safelymodulated via the neuromodulatory apparatus. Effectively applyingthermal treatment from within a renal artery is non-trivial given thepotential clinical complications associated with such treatment. Forexample, the intima and media of the renal artery are highly vulnerableto thermal injury. As discussed in greater detail below, theintima-media thickness separating the vessel lumen from its adventitiameans that target renal nerves may be multiple millimeters distant fromthe luminal surface of the artery. Sufficient energy should be deliveredto or heat removed from the target renal nerves to modulate the targetrenal nerves without excessively cooling or heating the vessel wall tothe extent that the wall is frozen, desiccated, or otherwise potentiallyaffected to an undesirable extent. A potential clinical complicationassociated with excessive heating is thrombus formation from coagulatingblood flowing through the artery. Given that this thrombus may cause akidney infarct, thereby causing irreversible damage to the kidney,thermal treatment from within the renal artery should be appliedcarefully. Accordingly, the complex fluid mechanics and thermodynamicconditions present in the renal artery during treatment, particularlythose that may impact heat transfer dynamics at the treatment site, maybe important in applying energy (e.g., heating thermal energy) and/orremoving heat from the tissue (e.g., cooling thermal conditions) fromwithin the renal artery.

The neuromodulatory apparatus should also be configured to allow foradjustable positioning and repositioning of the energy delivery elementwithin the renal artery since location of treatment may also impactclinical efficacy. For example, it may be tempting to apply a fullcircumferential treatment from within the renal artery given that therenal nerves may be spaced circumferentially around a renal artery. Insome situations, full-circle lesion likely resulting from a continuouscircumferential treatment may be potentially related to renal arterystenosis. Therefore, the formation of more complex lesions along alongitudinal dimension of the renal artery via the mesh structuresdescribed herein and/or repositioning of the neuromodulatory apparatusto multiple treatment locations may be desirable. It should be noted,however, that a benefit of creating a circumferential ablation mayoutweigh the potential of renal artery stenosis or the risk may bemitigated with certain embodiments or in certain patients and creating acircumferential ablation could be a goal. Additionally, variablepositioning and repositioning of the neuromodulatory apparatus may proveto be useful in circumstances where the renal artery is particularlytortuous or where there are proximal branch vessels off the renal arterymain vessel, making treatment in certain locations challenging.Manipulation of a device in a renal artery should also considermechanical injury imposed by the device on the renal artery. Motion of adevice in an artery, for example by inserting, manipulating, negotiatingbends and so forth, may contribute to dissection, perforation, denudingintima, or disrupting the interior elastic lamina.

Blood flow through a renal artery may be temporarily occluded for ashort time with minimal or no complications. However, occlusion for asignificant amount of time should be avoided because to prevent injuryto the kidney such as ischemia. It could be beneficial to avoidocclusion all together or, if occlusion is beneficial to the embodiment,to limit the duration of occlusion, for example to 2-5 minutes.

Based on the above described challenges of (1) renal arteryintervention, (2) consistent and stable placement of the treatmentelement against the vessel wall, (3) effective application of treatmentacross the vessel wall, (4) positioning and potentially repositioningthe treatment apparatus to allow for multiple treatment locations, and(5) avoiding or limiting duration of blood flow occlusion, variousindependent and dependent properties of the renal vasculature that maybe of interest include, for example, (a) vessel diameter, vessel length,intima-media thickness, coefficient of friction, and tortuosity; (b)distensibility, stiffness and modulus of elasticity of the vessel wall;(c) peak systolic, end-diastolic blood flow velocity, as well as themean systolic-diastolic peak blood flow velocity, and mean/maxvolumetric blood flow rate; (d) specific heat capacity of blood and/orof the vessel wall, thermal conductivity of blood and/or of the vesselwall, and/or thermal convectivity of blood flow past a vessel walltreatment site and/or radiative heat transfer; (e) renal artery motionrelative to the aorta induced by respiration, patient movement, and/orblood flow pulsatility: and (f) as well as the take-off angle of a renalartery relative to the aorta. These properties will be discussed ingreater detail with respect to the renal arteries. However, dependent onthe apparatus, systems and methods utilized to achieve renalneuromodulation, such properties of the renal arteries, also may guideand/or constrain design characteristics.

As noted above, an apparatus positioned within a renal artery shouldconform to the geometry of the artery. Renal artery vessel diameter,D_(RA), typically is in a range of about 2-10 mm, with most of thepatient population having a D_(RA) of about 4 mm to about 8 mm and anaverage of about 6 mm. Renal artery vessel length, L_(RA), between itsostium at the aorta/renal artery juncture and its distal branchings,generally is in a range of about 5-70 mm, and a significant portion ofthe patient population is in a range of about 20-50 mm. Since the targetrenal plexus is embedded within the adventitia of the renal artery, thecomposite Intima-Media Thickness, IMT, (i.e., the radial outwarddistance from the artery's luminal surface to the adventitia containingtarget neural structures) also is notable and generally is in a range ofabout 0.5-2.5 mm, with an average of about 1.5 mm. Although a certaindepth of treatment is important to reach the target neural fibers, thetreatment should not be too deep (e.g., >5 mm from inner wall of therenal artery) to avoid non-target tissue and anatomical structures suchas the renal vein.

An additional property of the renal artery that may be of interest isthe degree of renal motion relative to the aorta, induced by respirationand/or blood flow pulsatility. A patient's kidney, which located at thedistal end of the renal artery, may move as much as 4″ cranially withrespiratory excursion. This may impart significant motion to the renalartery connecting the aorta and the kidney, thereby requiring from theneuromodulatory apparatus a unique balance of stiffness and flexibilityto maintain contact between the thermal treatment element and the vesselwall during cycles of respiration. Furthermore, the take-off anglebetween the renal artery and the aorta may vary significantly betweenpatients, and also may vary dynamically within a patient, e.g., due tokidney motion. The take-off angle generally may be in a range of about30°-135°.

X. Conclusion

The above detailed descriptions of embodiments of the technology are notintended to be exhaustive or to limit the technology to the precise formdisclosed above. Although specific embodiments of, and examples for, thetechnology are described above for illustrative purposes, variousequivalent modifications are possible within the scope of thetechnology, as those skilled in the relevant art will recognize. Forexample, while steps are presented in a given order, alternativeembodiments may perform steps in a different order. The variousembodiments described herein may also be combined to provide furtherembodiments.

From the foregoing, it will be appreciated that specific embodiments ofthe technology have been described herein for purposes of illustration,but well-known structures and functions have not been shown or describedin detail to avoid unnecessarily obscuring the description of theembodiments of the technology. Where the context permits, singular orplural terms may also include the plural or singular term, respectively.

Moreover, unless the word “or” is expressly limited to mean only asingle item exclusive from the other items in reference to a list of twoor more items, then the use of “or” in such a list is to be interpretedas including (a) any single item in the list, (b) all of the items inthe list, or (c) any combination of the items in the list. Additionally,the term “comprising” is used throughout to mean including at least therecited feature(s) such that any greater number of the same featureand/or additional types of other features are not precluded. It willalso be appreciated that specific embodiments have been described hereinfor purposes of illustration, but that various modifications may be madewithout deviating from the technology. Further, while advantagesassociated with certain embodiments of the technology have beendescribed in the context of those embodiments, other embodiments mayalso exhibit such advantages, and not all embodiments need necessarilyexhibit such advantages to fall within the scope of the technology.Accordingly, the disclosure and associated technology can encompassother embodiments not expressly shown or described herein.

1-33. (canceled) 34: A system comprising: an output device; andprocessing circuitry configured to: determine a first probability ofsuccessful treatment based on a value associated with a first variablerelating to a renal neuromodulation procedure; in response to the firstprobability of successful treatment being unfavorable, determine asecond probability of successful treatment based on a value associatedwith a second variable relating to the renal neuromodulation procedure,wherein the second variable is different from the first variable; inresponse to the second probability of successful treatment beingfavorable, outputting an indication of acceptable treatment via theoutput device. 35: The system of claim 34, wherein the processingcircuitry is further configured to: in response to the secondprobability of successful treatment being unfavorable, analyze the firstvariable and the second variable in combination to determine a thirdprobability of successful treatment; and output an indication of anoutput of the analysis via the output device. 36: The system of claim35, wherein the processing circuitry is configured to analyze the firstvariable and the second variable in combination to determine the thirdprobability of successful treatment by at least: determining a scorebased on the first variable and the second variable. 37: The system ofclaim 36, wherein the processing circuitry is configured to analyze thefirst variable and the second variable in combination to determine thethird probability of successful treatment by at least: performing alinear discriminant analysis (LDA) on the first variable and the secondvariable. 38: The system of claim 37, wherein the processing circuitryis configured to perform the LDA on the first variable and the secondvariable by at least: applying corresponding coefficients to each of thefirst variable and the second variable to determine weighted variablesand summing the weighted variables. 39: The system of claim 34, whereinthe first variable is indicative of inconsistent contact between anelectrode and a vessel wall. 40: The system of claim 34, wherein atleast one of the first variable or the second variable comprises atleast one of a temperature change during at least a portion of the renalneuromodulation procedure, a maximum average temperature during at leasta portion of the renal neuromodulation procedure, a mean averagetemperature during at least a portion of the renal neuromodulationprocedure, a change in impedance during at least a portion of the renalneuromodulation procedure, an output power during at least a portion ofthe renal neuromodulation procedure, a standard deviation of atemperature during at least a portion of the renal neuromodulationprocedure, or a standard deviation of an impedance during at least aportion of the renal neuromodulation procedure. 41: The system of claim40, wherein: the first variable comprises the temperature change duringthe at least the portion of the renal neuromodulation procedure, the atleast the portion comprises a time period from a start of the renalneuromodulation procedure to a first time, the processing circuitry isconfigured to compare the temperature change to a threshold temperaturechange value, and the processing circuitry is configured to determinethe first probability of successful treatment to be unfavorable inresponse to the temperature change being less than the thresholdtemperature change value. 42: The system of claim 40, wherein: thesecond variable comprises the maximum average temperature during the atleast the portion of the renal neuromodulation procedure, the processingcircuitry is configured to compare the maximum average temperature to athreshold temperature value, and the processing circuitry is configuredto determine the second probability of successful treatment to beunfavorable in response to the maximum average temperature being lessthan the threshold temperature value. 43: The system of claim 40,wherein: the second variable comprises the mean temperature during theat least the portion of the renal neuromodulation procedure, the atleast the portion comprises a time period after an initial power ramp,the processing circuitry is configured to compare the mean temperatureto a threshold temperature value, and the processing circuitry isconfigured to determine the second probability of successful treatmentto be unfavorable in response to the mean temperature being less thanthe threshold temperature value. 44: The system of claim 40, wherein:the second variable comprises the change in impedance during at leastthe portion of the renal neuromodulation procedure, the processingcircuitry is configured to compare the change in impedance to athreshold impedance change value, and the processing circuitry isconfigured to determine the second probability of successful treatmentto be unfavorable in response to the change in impedance being less thanthe threshold temperature value. 45: A system comprising: an outputdevice; and processing circuitry configured to: receive a value for eachvariable of a set of N variables relating to a renal neuromodulationprocedure; determine a first probability of successful treatment basedon the value of a first variable from the set of N variables; inresponse to the first probability of successful treatment beingunfavorable, successively determine a corresponding probability ofsuccessful treatment based on the corresponding value of each successivevariable from the set of N variables until a corresponding probabilityof a successful treatment is favorable or a corresponding probability ofsuccessful treatment has been determined for each variable of the set ofN variables; in response to a corresponding probability of successfultreatment associated with the one of the successive variables beingfavorable, outputting an indication of acceptable treatment via theoutput device and not determining any additional correspondingprobability of successful treatments. 46: A method comprising:determining, by processing circuitry, a first probability of successfultreatment based on a value associated with a first variable relating toa renal neuromodulation procedure; in response to the first probabilityof successful treatment being unfavorable, determining, by theprocessing circuitry, a second probability of successful treatment basedon a value associated with a second variable relating to the renalneuromodulation procedure, wherein the second variable is different fromthe first variable; in response to the second probability of successfultreatment being favorable, outputting, by the processing circuitry to anoutput device, an indication of acceptable treatment. 47: The method ofclaim 46, further comprising: in response to the second probability ofsuccessful treatment being unfavorable, analyzing, by the processingcircuitry, the first variable and the second variable in combination todetermine a third probability of successful treatment; and outputting,by the processing circuitry, an indication of an output of the analysisvia the output device. 48: The method of claim 47, wherein analyzing thefirst variable and the second variable in combination to determine thethird probability of successful treatment comprises determining, by theprocessing circuitry, a score based on the first variable and the secondvariable. 49: The method of claim 48, analyzing the first variable andthe second variable in combination to determine the third probability ofsuccessful treatment comprises performing, by the processing circuitry,a linear discriminant analysis (LDA) on the first variable and thesecond variable. 50: The method of claim 49, wherein performing the LDAon the first variable and the second variable comprises applying, by theprocessing circuitry, corresponding coefficients to each of the firstvariable and the second variable to determine weighted variables andsumming the weighted variables. 51: The method of claim 46, wherein thefirst variable is indicative of inconsistent contact between anelectrode and a vessel wall. 52: The method of claim 46, wherein atleast one of the first variable or the second variable comprises atleast one of a temperature change during at least a portion of the renalneuromodulation procedure, a maximum average temperature during at leasta portion of the renal neuromodulation procedure, a mean averagetemperature during at least a portion of the renal neuromodulationprocedure, a change in impedance during at least a portion of the renalneuromodulation procedure, an output power during at least a portion ofthe renal neuromodulation procedure, a standard deviation of atemperature during at least a portion of the renal neuromodulationprocedure, or a standard deviation of an impedance during at least aportion of the renal neuromodulation procedure. 53: The method of claim52, wherein: the first variable comprises the temperature change duringthe at least the portion of the renal neuromodulation procedure, the atleast a portion comprises a time period from a start of the renalneuromodulation procedure to a first time, determining the firstprobability of successful treatment based on the value associated withthe first variable comprises: comparing, by the processing circuitry,the temperature change to a threshold temperature change value, anddetermining, by the processing circuitry, the first probability ofsuccessful treatment to be unfavorable in response to the temperaturechange being less than the threshold temperature change value. 54: Themethod of claim 52, wherein: the second variable comprises the maximumaverage temperature during the at least the portion of the renalneuromodulation procedure, determining the second probability ofsuccessful treatment based on the value associated with the secondvariable comprises: comparing, by the processing circuitry, the maximumaverage temperature to a threshold temperature value, and determining,by the processing circuitry, the second probability of successfultreatment to be unfavorable in response to the maximum averagetemperature being less than the threshold temperature value. 55: Themethod of claim 52, wherein: the second variable comprises the meantemperature during the at least the portion of the renal neuromodulationprocedure, the at least a portion comprises a time period after aninitial power ramp, determining the second probability of successfultreatment based on the value associated with the second variablecomprises: comparing, by the processing circuitry, the mean temperatureto a threshold temperature value, and determining, by the processingcircuitry, the second probability of successful treatment to beunfavorable in response to the mean temperature being less than thethreshold temperature value. 56: The method of claim 52, wherein: thesecond variable comprises the change in impedance during at least theportion of the renal neuromodulation procedure, determining the secondprobability of successful treatment based on the value associated withthe second variable comprises: comparing, by the processing circuitry,the change in impedance to a threshold impedance change value, anddetermining, by the processing circuitry, the second probability ofsuccessful treatment to be unfavorable in response to the change inimpedance being less than the threshold temperature value.